Patient Safety Zone

Glossary

A to Z of terms related to patient safety.

Glossary of Terms

A| B| C | D | E |F |G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z
 

A

Active error
Active errors are committed by frontline staff and tend to have direct patient consequences.

Adaptive mechanisms
Humans have adaptive mechanisms (tendencies) that function as 'short-cuts' by 'launching pre-programmed' actions when confronted with problems. They generally serve us well, but can also predispose us to error in unusual or different situations.

Adverse event
An adverse event occurred if a patient was injured by healthcare intervention rather than an underlying condition.

Availability heuristic
Availability heuristic is a specific example of an adaptive mechanism that we use to deal with complex or new situations. The mechanism's implication is that the majority of people give undue weight to facts that come readily to mind, while other options are 'ignored'. This mechanism is also sometimes referred to as 'cognitive tunnel vision'.

B

Blame culture
The traditional response to adverse incidents in health care, which had been to blame, shame and punish individuals. It is the opposite of a no-blame culture.

C

Checklists
Checklists are structured reminders that help to improve adherence to clinical guidelines and helps to compensate for memory or attention failures. A checklist is an example of a specific method that can be used in a systems approach to manage error effectively.

Close call
A 'close call' is any incident that could have led to harm but did not, either by chance or through timely intervention. See also: 'near miss' and 'free lesson'.

Cognitive tunnel vision
Cognitive tunnel vision or the availability heuristic is a specific example of an adaptive mechanism that we use to deal with complex or new situations. The mechanism's implication is that the majority of people give undue weight to facts that come readily to mind, while other options are 'ignored'.

Confirmation bias
Confirmation bias is a specific example of an adaptive mechanism that we use to deal with complex or new situations. The mechanism's implication is that the majority of people tend to select evidence to support their choice.

D

Drift
Drift is the incremental accumulation of violations. One example is 'cutting corners' by omitting steps of a familiar process.

E

Error
Error is the result of choosing the wrong plan to achieve an aim, or not initiating or completing the right plan as intended. Errors are unintentional and should not be confused with violations, negligence or recklessness.

Error myths
Error myths are common misperceptions held by many health care workers and policy makers about error. Specific error myths are:

  • Errors are intrinsically 'bad'
  • Errors are random
  • Health care staff rarely makes errors
  • 'Bad' people make errors
  • It is easier to change people than systems

Error traps
Error traps or 'resident pathogens' are the latent (system) errors that contribute to patient safety incidents, but are missed during reporting and analysis. This can happen when the focus of analysis is solely the individual and the incident is stripped of all contexts. A 'blame culture' discourages reporting, leading to further lost opportunities to identify error traps before they cause future harm.

Return to top

F

Forcing function
A forcing function is a task that has to be completed or confirmed before any further action can be taken. It is an example of a specific method that can be used in a systems approach to manage error effectively.

Free lesson
A 'free lesson' is any incident that could have led to harm but did not, either by chance or through timely intervention. See also: 'close call' and 'free lesson'.

Frequency gambling
Frequency gambling is a specific example of an adaptive mechanism that we use to deal with complex or new situations. The mechanism's implication is that the majority of people tend to select the option that occurs more frequently when they have to make a quick decision.

Fundamental attribution bias
One of the psychological factors that predispose us to blame individuals after patient safety incidents. Our natural tendency is to attribute someone's actions (especially undesirable actions) to their personality traits or characteristics while (unintentionally) ignoring circumstantial factors that may have constrained their actions.

H

Harm
Harm occurred if a patient's health or quality of life is negatively affected by any aspect of their interaction with health care. A pragmatic interpretation is 'anything' that you would not want to happen to you or your relatives while receiving care.

Healthcare Improvement Scotland (HIS)
Healthcare Improvement Scotland (HIS) is a special board that co-ordinate or lead a number of patient safety-related projects. They work in close partnership with various agencies and NHS Boards to help improve risk management, raise awareness of patient safety and to promote incident reporting

Health Foundation
The Health Foundation is an independent charity based in London that aims to improve the quality of healthcare across the United Kingdom and beyond. They have commissioned, undertaken and/or supported a large number of patient safety and quality improvement projects.

Hindsight bias
One of the psychological factors that predispose us to blame individuals after patient safety incidents. Our knowledge of a patient safety incident's outcome unconsciously influences our perceptions of others' actions. Warning signs appear more obvious and consequences more foreseeable than they would have been to those involved. It is sometimes referred to as the 'I-knew-it-all-along' effect.

HSC Safety Forum
The HSC Safety Forum is a patient safety initiative that was launched in Northern Ireland in 2008. Their aims were to: treat patient as partners; develop a network of knowledge; create learning sets and collaboratives; promote clinical, social care and executive leadership; measure and demonstrate impact; promote innovation; tailor interventions to the needs of specific organisations or practices.

Human factors
Human factors is the discipline that studies the environmental, organizational and job factors and the human and individual characteristics which influence behaviour at work in a way which can affect health and safety.

Human limitations
Skills and abilities vary widely between people, but all of us eventually reach our natural limits. As we come closer to or exceed these limits we are increasingly left vulnerable to making errors. Examples of ways in which we are limited include: attention span, memory, situation awareness and personal resources.

I

Illusion of free will
One of the psychological factors that predispose us to blame individuals after patient safety incidents. Most of us belief that we determine our own actions (most of the time) - we impute this automatically to other people even when their actions were not intended. In other words, they 'choose' to err.

Incident Record 1
An incident Record 1 (IR1) form has to be completed for staff, patients and the public after an incident to report what had happened. The IR1 will prompt you to also report the incident to the Health and Safety Executive (HSE) if necessary.

Involuntary automaticity
Involuntary automaticity is a specific example of an adaptive mechanism that we use to deal with complex or new situations. The mechanism's implication is that the majority of people tend to complete patterns by filling in 'blanks'.

Return to top

J

Just culture
A just culture is one that strikes an appropriate balance between 'blame' and 'no blame' and is transparent and acceptable to everyone concerned.

'Just world' hypothesis
One of the psychological factors that predispose us to blame individuals after patient safety incidents. This is the assumption that 'bad' things only happen to 'bad' people. When taken to extreme, even victims are blamed for their misfortune.

K

Knowledge-based errors
Any error that results from a deficit of knowledge. A person may intend to implement a plan or action, but the plan or action is incomplete or flawed by a lack of knowledge and so do not achieve a desired outcome. It is one of the three possible groups into which all human error can be classified.

L

Lapse
A lapse is a specific type of error, caused by a plan (or part of a plan) not being executed. They are usually the result of memory failures.

Latent errors
Latent or system errors create the conditions, context and potential for active errors. They seldom have immediate consequences, but can potentially affect many more patients.

M

Mistake
A mistake is a specific type of error, caused by choosing or executing the wrong plan.

N

National reporting systems
National reporting systems collect specific data systematically. Their findings and recommendations are published periodically. Examples include:

  • Serious Hazards of Transfusion
  • Scottish Surveillance of Healthcare Associated Infection Programme
  • Scottish Audit of Surgical Mortality
  • Confidential Inquiry into Maternal and Child Health


Near miss
A 'near miss' is any incident that could have led to harm but did not, either by chance or through timely intervention. See also: 'close call' and 'free lesson'.

NHS Education for Scotland (NES)
NES is a special board committed to developing an integrated educational partnership framework that will support patient safety initiatives across NHS Scotland. The interested reader can find examples and more information about a range of activities and educational resources on our patient safety website. [http://www.nes.scot.nhs.uk/initiatives/patient-safety]

Negligence
Professional negligence or medical malpractice occurs when a health care worker, by act or omission, deviates from accepted standards of practice and causes injury or death to a patient, whether intentional or unintentional. Cases of negligence are usually dealt with under civil law.

Return to top

O

1000 Lives Campaign
The 1000 lives campaign is a patient safety initiative that was launched in Wales in 2008. Their aims were to improve patient safety and increase healthcare quality across Wales and to prevent 1000 deaths and 50,000 episodes of harm.

P

Patient safety
Patient safety is freedom from healthcare associated, preventable harm. A simple explanation is that 'when things go right, nothing bad happens.'

Patient Safety First
The Patient Safety First (PSF) is a safety initiative that was launched in England in 2008. The aims were to promote leadership for safety and to reduce harm from clinical deterioration in hospitalized patients, to reduce harm rates in critical and peri-operative care and to reduce harm resulting from high-risk medicines

Patient safety incident
A patient safety incident is any healthcare related incident that was unintended, unexpected and undesired and that could have or did cause harm to patients.

Pattern-matching
Pattern matching is a specific example of an adaptive mechanism that we use to deal with complex or new situations. The mechanism's implication is that most people will form an impression by observing the whole, rather than by scrutinizing every detail.

Previous success
Previous success is a specific example of an adaptive mechanism that we use to deal with complex or new situations. The mechanism's implication is that if there are a number of options, most people will choose the option they have chosen before, or that they have some knowledge of.

R

Recklessness
Someone is considered to have acted recklessly if they took a deliberate and unjustifiable risk. Cases of recklessness are usually dealt with under criminal law.

Redundancies
A redundancy is a repetition of a task or confirmation (a 'double check'). It is an example of a specific method that can be used in a systems approach to manage error effectively.

Resident pathogens
'Resident pathogens' or error traps are the latent (system) errors that contribute to patient safety incidents, but are missed during reporting and analysis. This can happen when the focus of analysis is solely the individual and the incident is stripped of all contexts. A 'blame culture' discourages reporting, leading to further lost opportunities to identify resident pathogens before they cause future harm.

Root Cause Analysis
Root Cause Analysis (RCA) is one method that can be used to try and find the cause(s) of a serious patient safety incident. It is time and resource intensive, usually involves a multidisciplinary group and may include people that were not involved in the incident.

Rule-based errors
Any error that results when a known rule is incorrectly applied or a situation is misinterpreted. It is one of the three possible groups into which all human error can be classified.

Return to top

S

Safer Patients Initiative (SPI)
The Safer Patients Initiative (SPI) was one of the first organised attempts to improve patient safety in the UK. It was commissioned by the Health Foundation to address the problem of preventable harm in secondary care. Twenty four hospital sites participated during two phases that ran from 2004 until 2008.

Safer Patients Network
The Health Foundation launched the Safer Patients Network in June 2009. The vision for the network was to create a self-sustaining, member-driven community of practices to catalyse improvements in patient safety. The networks aims to help test, develop and export approaches and methods that will make healthcare safer for patients in the UK and beyond.

Safety culture
Safety culture is commonly defined as the product of individual and group values, attitudes, perceptions and patterns of behaviour that determine a team or organisation's commitment to safety management.

SBAR
SBAR is a communication technique adapted from the US Navy. It can help health care professionals to structure the information they are trying to communicate to a colleague. The acronym stands for:
S = Situation
B = Background
A = Assessment
R = Recommendation

Scottish Patient Safety Programme
The Scottish Patient Safety Programme (SPSS) is a five year patient safety initiative that was launched in Scotland in 2008. The aims were to reduce secondary care mortality by 15% and morbidity by 30%. Specific objectives were to reduce healthcare associated infections, adverse surgical and drug incidents, to improve critical care outcomes and build a safety and quality culture.

Significant event
A significant event is any event thought by anyone in the team to be significant in the care of patients or the conduct of the organization. Significant events can be positive or negative.

Significant Event Analysis (SEA)
Significant Event Analysis (SEA) is a validated method that can help individuals and teams learn from patient safety incidents. SEA is embedded in primary care as part of contractual, educational and appraisal obligations.

Skill-based errors
Any error that occurs when a person's actions are different to their intentions. These errors often occur during automatic behaviours which require little conscious thought, or when our attention is being diverted. It is one of the three possible groups into which all human error can be classified.

Slips
A slip is a specific type of error, caused by incorrectly executed plans. Slips are usually the result of attention failures.

System errors
System or latent errors create the conditions, context and potential for active errors. They seldom have immediate consequences, but can potentially affect many more patients.

Swiss cheese model
Professor James Reason proposed this model to illustrate active and latent errors. In this model, the slices of cheese represent the various system defenses between hazards and adverse events and the holes represent active and latent (system) errors. The slices of cheese are in constant motion. The holes generally do not form a straight line, with at least one slice blocking hazards from reaching patients. Most incidents of harm occur when the holes in the slices of cheese (the active and system errors) temporarily align, allowing hazards to reach patients.

Return to top

T

Three buckets model
Professor Reason proposed the 'three buckets model' to help health care workers evaluate their error risk. The three buckets represent the potential risk posed by 'self', 'context' and 'task'. The amount of perceived risk in each 'bucket' is rated in turn by the health care worker as (1) low, (2) medium or (3) high.

V

Violation
Violations are deliberate actions that are inconsistent with rules or recommended practice familiar to a health care worker. Violations are not necessarily deviant behaviour, but may sometimes be adaptive behaviour in response to complex, challenging or demanding situations.

Helpdesk