Trainer - Page 3

Glossary of Terms

Accreditation Watch – An attribute of an organization’s Joint Commission accreditation status. A health care organization is placed on Accreditation Watch when a reviewable sentinel event has occurred and has come to the attention of The Joint Commission and a thorough and credible root cause analysis of the sentinel event and action plan have not been completed within a specified time frame.

Action plan – The product of the root cause analysis that identifies the strategies that an organization intends to implement to reduce the risk of similar events occurring in the future. The plan should address responsibility for implementation, oversight, pilot testing as appropriate, time lines and strategies for measuring the effectiveness of the actions.

Adverse drug event (adverse drug error) - Any incident in which the use of a medication (drug or biologic) at any dose, a medical device or a special nutritional product (for example, dietary supplement, infant formula, medical food) may have resulted in an adverse outcome in a patient

Adverse drug reaction (ADR) – an undesirable response associated with use of a drug that either compromises therapeutic efficacy, enhances toxicity, or both

Adverse event – an untoward, undesirable and usually unanticipated event, such as death of a patient, an employee or a visitor in a health care organization. Incidents such as patient falls or improper administration of medications are also considered adverse events, even if there is no permanent effect on the patient.

Causation – the act by which an effect is produced. In epidemiology, the doctrine of causation is used to relate certain factors (predisposing, enabling, precipitating or reinforcing factors_ to disease occurrence. The doctrine of causation is also important in the fields of negligence and criminal law. Synonym: causality.

Disclosure – communication of information regarding the results of a diagnostic test, medical treatment or surgical intervention

Error of commission – an error that occurs as a result of an action taken. Examples include when a drug is administered at the wrong time, in the wrong dosage or using the wrong route; surgeries performed on the wrong side of the body; and transfusion errors involving blood cross-matched for another patient.

Error of omission – an error that occurs as a result of an action not taken, for example, when a delay in performing an indicated cesarean section results in a fetal death, when a nurse omits a dose of a medication that should be administered, or when a patient suicide is associated with a lapse in carrying out frequent patient checks on a psychiatric unit. Errors of omission may or may not lead to adverse outcomes.

Flow chart/diagram – a pictorial summary that shows with symbols and words the steps, sequence and relationship of the various operations involved in the performance of a function or a process

FMEA (Failure Mode Effects Analysis) – a systematic approach of examining a design prospectively for possible ways in that failure can occur. It assumes that no matter how knowledgeable or careful people are, errors will occur in some situations and may even be likely to occur.

Incident report – the documentation for any unusual problem, incident or other situation that is likely to lead to undesirable effects or that varies from established policies and procedures or practices.

Malpractice – improper or unethical conduct or unreasonable lack of skill by a holder of a professional or official position; often applied to physicians, dentists, lawyers and public officers to denote negligent or unskillful performance of duties when professional skills are obligatory. Malpractice is a cause of action for which damages are allowed.

Negligence – failure to use such care as a reasonable prudent and careful person would use under similar circumstances

Plan-do-study-act (PDSA) cycle – a four-part method for discovering and correcting assignable causes to improve the quality of processes. Synonyms: Deming cycle; Shewhart cycle.

Process – a goal-directed, interrelated series of actions, events, mechanisms or steps

Proximate cause/factors – an act or omission that naturally and directly produces a consequence. It is the superficial or obvious cause for an occurrence. Treating only the “symptoms” or the proximate special cause may lead to some short-term improvements, but will not prevent the variation from recurring.

Risk containment – immediate actions taken to safeguard patients from a repetition of an unwanted occurrence. Actions may involve removing and sequestering drug stocks from pharmacy shelves and checking or replacing oxygen supplies or specific medical devices

Risk management – clinical and administrative activities undertaken to identify, evaluate and reduce the risk of injury to patients, staff and visitors and the risk of loss to the organization itself.

Root cause – the most fundamental reason for the failure or inefficiency of a process

Root cause analysis – a process for identifying the basic or causal factor(s) that underlie variation in performance, including the occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called “sentinel” because they signal the need for immediate investigation and response.

Sentinel event – an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, “or risk thereof” includes any process variation for which a recurrence would carry a significant change of a serious adverse outcome. Such events are called “sentinel” because they signal the need for immediate investigation and response.

Unanticipated outcome – a result that differs significantly from what was anticipated to be the result of a treatment or procedure

Variation – the differences in results obtained in measuring the same phenomenon more than once. The sources of variation in a process over time can be grouped into two major classes: common causes and special causes. Excessive variation frequently leads to waste and loss, such as the occurrence of undesirable patient health outcomes and increased cost of health services. Common-cause variation, also called endogenous cause variation or systemic cause variation, in a process is due to the process itself and is produced by interactions of variables of that process is inherent in all processes, not a disturbance in the process. It can be removed only by making basic changes in the process. Special-cause variation, also called exogenous-cause variation or extra-systemic cause variation, in performance results from assignable causes. Special-cause variation is intermittent, unpredictable and unstable. It is not inherently present in a system; rather, it arises from causes that are not part of the system as designed occurrence or possible occurrence of a sentinel event.