Patient safety glossary

This glossary provides definitions of selected terms from authoritative sources and also aims to show how terms and concepts are presented and interpreted in current policy and practice. There are links to the sources of the quotations where possible.

Some of the sources are in PDF format - see how to access PDF files.

Active failure

"An unsafe act or omission by someone (a doctor, a nurse, a pilot) whose actions can have an immediate effect."
Source: Reason J (1997) Managing the risks of organizational accidents. Aldershot: Ashgate Publishing chapter 1.
 
"The unsafe acts committed by people who may be in direct contact with an accident victim or a particular system.  Such failures take a number of forms - slips, lapses, mistakes and procedural violations..."
Source: Stranks J (2007)  Human factors and behavioural safety. Amsterdam: Elsevier p.130.

Adverse event

"An adverse event is an injury caused by medical management rather than the underlying condition of the patient."
Source: Institute of Medicine (2000) To err is human: Building a safer health system. Washington: National Academies Press p.28.

"An event or omission arising during clinical care and causing physical or psychological injury to a patient."
Source: Department of Health (2000) An organisation with a memory. London: The Stationery Office p.xii.

Critical errors

"... are associated with… lack of attention to the task, incorrect visual perceptions, loss of balance and over-reaching, the latter resulting in falls. The indirect causes of these errors could be fatigue, stress, rushing to complete a task, complacency and overconfidence…"
Source: Stranks J (2007)  Human factors and behavioural safety.  Amsterdam: Elsevier p.436.

Deterioration / clinical deterioration / patient deterioration

“Clinical deterioration can happen at any point in a patient’s illness, or care process,
but patients are particularly vulnerable following an emergency admission to
hospital, after surgery and during recovery from a critical illness”.

The findings of a study published by the National Patient Safety Agency  indicated that “consistently and effectively detecting and acting upon patient deterioration is a complex issue” and  identified some of the points at which the process can fail as “not taking observations, not recognising early signs of deterioration, not communicating observations causing concern and not responding to these appropriately”.
Source: National Patient Safety Agency (2007) Recognising and responding appropriately to early signs of deterioration in hospitalised patients. London: NPSA pp.6,8.

A ‘How to guide’ on reducing harm from deterioration published by Patient Safety which aims to support staff in implementing the NICE guidance on acutely ill patients in hospital describes six  key areas of an intervention:

• Physiological observations should be recorded for all adult patients in acute hospital settings.
• Physiological observations should be recorded and acted upon by staff who have been trained to undertake these procedures and understand their clinical relevance.
• Physiological track and trigger systems should be used.
• There should be a graded response strategy.
• An escalation protocol should be in place.
• A communication tool should be used.”

Source: Patient Safety First (2008) The ‘How to guide’ for reducing harm from deterioration. London: Patient Safety p.7. 

Errors 

"... are shaped and provoked by upstream work and organizational factors. Identifying an error is merely the beginning of the search for causes, not the end."
Source: Reason J (1997) Managing the risks of organizational accidents. Aldershot: Ashgate Publishing p.126.

"... are the unintentional violations caused by knowledge and skill deficiencies."
Source: Stranks J (2007) Human factors and behavioural safety. Amsterdam: Elsevier p.436.

"An act of commission (doing something wrong) or omission (failing to do the right thing) that leads to an undesirable outcome or significant potential for such an outcome."
Source: Agency for Healthcare Research and Quality, PS Net (Patient Safety Network) glossary. AHRQ website.

Foresight

“The ability of frontline healthcare staff to identify, respond to and recover from the initial indications that a patient safety incident could take place.”
Source: National Patient Safety Agency (2008) Foresight training resource pack1: introduction to foresight and foresight training. London: NPSA p.1.

“Foresight skills include intuition, wariness and vigilance”
Source: National Patient Safety Agency (2008) Foresight training resource pack 3: presentation. Slide 4. London: NPSA.

Harm

“Harm implies impairment of structure or function of the body and/or any deleterious effect arising there from, including disease, injury, suffering, disability and death, and may be physical, social or psychological”.
Source: World Health Organization (2009) Conceptual framework for the International Classification for Patient Safety version 1.1: final technical report. Geneva: WHO p.16. (n.b. you are required to complete a registration form to access the downloadable report).

Health care error

"An unintended healthcare outcome caused by a defect in the delivery of care to a patient.  These may be errors of commission, errors of omission, errors of execution, and may be made by any member of the healthcare team in any healthcare setting."
Source: National Patient Safety Foundation website (2003) Our definitions. NPSF website (About us page).

Human error

"... is associated with limitations in human capacity to perceive, attend to, remember, process and act on information and is associated with lapses of attention, mistaken actions, misperceptions, mistaken priorities and, in some cases, wilfulness."
Source: Stranks J (2007) Human factors and behavioural safety. Amsterdam: Elsevier p.451.

"Two approaches to the problem of human fallibility exist: the person and the system approaches…..
The person approach focuses on the errors of individuals, blaming them for forgetfulness, inattention, or moral weakness."
Source: Reason J (2000) Human error: models and management  British Medical Journal 320 18 March pp. 768-770 (p.768).

Human factors

"A term covering a wide range of issues, which include:
- the perpetual, physical and mental capabilities of people and the interaction of individuals with their job and the work environment
- the influence of equipment and system design on human performance
- the organizational characteristics which influence safety-related behaviour at work.
These issues are affected by:
- the system for communication within the organization, and
- the training systems and procedures in operation."
Source: Stranks J (2007)  Human factors and behavioural safety. Amsterdam: Elsevier p.451.

Lapses

"The actions of forgetting to carry out a task or action, to lose the place in a task or forgetting what an individual intended to do".
Source: Stranks J (2007) Human factors and behavioural safety. Amsterdam: Elsevier p.453.

Latent conditions / latent error

"Errors in the design, organization, training, or maintenance that lead to operator errors and whose effects typically lie dormant in the system for lengthy periods of time".
Source: Institute of Medicine (2000) To err is human: Building a safer health system. Washington: National Academies Press p.210.

"They relate to aspects of the system in which people work. They are usually actions or decisions taken at the higher levels of an organisation, which seem well thought out and appropriate at the time but can create potential problems within the system……The latent conditions combined with local conditions (active failures and contributory factors) create the potential for incidents to happen".
Source: National Patient Safety Agency (2004) Seven steps to patient safety: full reference guide. London: NPSA p.25.

Missed nursing care

“Missed nursing care is a newly defined concept and refers to any aspect of required patient care that is omitted (either in part or in whole) or delayed. Missed nursing care is an error of omission. The patient safety movement has identified two major types of errors – acts of commission (such as marking the incorrect eye for surgery) and acts of omission (such as not ambulating the patient)”.

Source: Kalish BJ, Landstrom GL, Hinshaw AS (2009) Missed nursing care: a concept analysis. Journal of Advanced Nursing 65(7) July pp.1509-1517. (Quote from page 1510).
The full text of the article can be accessed via the RCN e-journals.

Mistake

"A form of human error where an individual shows awareness of a problem, but forms a faulty plan for solving it.  The situation where an individual does the wrong thing believing it to be correct".
Source: Stranks J (2007) Human factors and behavioural safety. Amsterdam: Elsevier p.454.

Near miss

"Situations that could have resulted in an accident, injury or illness for a patient but were avoided by chance or by intervention."
Source: Milligan F (2007) Malicious and inept practice (in) Currie L (Ed) Understanding Patient Safety. London: Quay Books p.55.

Never events

"Serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented."
Source: National Patient Safety Agency (2009) Never events. NPSA website para1.

Non-technical skills

"…The cognitive, social and personal resource skills that complement technical skills, and contribute to safe and efficient task performance."
Source: Flin R et al (2008) Safety at the sharp end: A guide to non-technical skills.  Farnham: Ashgate p.1.

Patient safety

"The process by which an organisation makes patient care safer. This should involve: risk assessment; the identification and management of patient-related risks; the reporting and analysis of incidents; and the capacity to learn from and follow-up on incidents and implement solutions to minimise the risk of them recurring."
Source: National Patient Safety Agency (2004) Seven steps to patient safety: full reference guide. London: NPSA p.17.

"Freedom from accidental injury." 
Source: Mohr J et al (2004) Integrating patient safety into clinical microsystems. Quality & Safety in Healthcare 13 (Suppl II) pp.ii34-ii38.

"The prevention of healthcare errors, and the elimination or mitigation of patient injury caused by healthcare errors."
Source: National Patient Safety Foundation (2003) Our definitions. NPSF website (About us page).

Patient safety incident

"Any unintended or unexpected incident(s) that could have or did lead to harm for one or more patients receiving NHS-funded healthcare."
Source: National Patient Safety Agency (2004) Seven steps to patient safety: full reference guide. London: NPSA p.97.

Risk management

"Identifying, assessing, analysing, understanding and acting on risk issues in order to reach an optimal balance of risk, benefit and cost."
Source: National Patient Safety Agency (2004) Seven steps to patient safety: full reference guide. London: NPSA p.29.

Safety climate

"A climate that promotes staff commitment to health and safety, emphasizing that deviation from corporate safety goals, at whatever level, is not acceptable."
Source: Stranks J (2007) Human factors and behavioural safety. Amsterdam: Elsevier p.457.

Safety culture

"The promotion of a positive climate in which health and safety are seen by both management and employers as being fundamental to the organization's day-to-day operations."
 
"The shared beliefs, practices and attitudes that exist within an organization with respect to safety."
 
"The product of the individual and group values, attitudes, competencies and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organization's health and safety programme. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventative measures."
Source: Stranks J (2007)  Human factors and behavioural safety. Amsterdam: Elsevier p.457.

SBAR – Situation – Background – Assessment – Recommendation

“SBAR is an easy to remember mechanism that you can use to frame conversations, especially critical ones, requiring a clinician's immediate attention and action. It enables you to clarify what information should be communicated between members of the team, and how. It can also help you to develop teamwork and foster a culture of patient safety. 

The tool consists of standardised prompt questions within four sections, to ensure that staff are sharing concise and focused information. It allows staff to communicate assertively and effectively, reducing the need for repetition”.
Source: NHS Institute for Innovation and Improvement. SBAR – Situation – Background – Assessment – Recommendation. NHS Institute website, para1-2.

Situational awareness

“Refers to the degree to which one’s perception of a situation matches reality. In the context of crisis management, where the phrase is most often used, situational awareness includes awareness of fatigue and stress among team members (including oneself), environmental threats to safety, appropriate immediate goals, and the deteriorating status of the crisis (or patient). Failure to maintain situational awareness can result in various problems that compound the crisis…”
Source: Agency for Healthcare Research and Quality, PS Net (Patient Safety Network) glossary. AHRQ website.

"In essence, SA involves continuously monitoring what is happening in the task environment in order to understand what is going on and what might happen in the next minutes or hours....On most jobs, the worker needs to have a good ‘mental model’ (picture in their head) representing the status of their current task and the risks within the surrounding work environment".
Source: World Health Organization (2009) Human factors in patient safety: review of topics and tools. (Available as Human factors review on the WHO Patient safety human factors page). Geneva: WHO pp.33-34.

Slips

"Failures in carrying out the actions of a task, that is, actions not as planned."
Source: Stranks J (2007)  Human factors and behavioural safety. Amsterdam: Elsevier p.458.

System

"Set of interdependent elements interacting to achieve a common aim.  These elements may be both human and nonhuman (equipment, technologies, etc)."
Source: Institute of Medicine (2000) To err is human. Washington: National Academy Press p. 211.

System error

"Two approaches to the problem of human fallibility exist: the person and the system approaches… The system approach concentrates on the conditions under which individuals work and tries to build defences to avert errors or mitigate their effects."
Source: Reason J (2000) Human error: models and management British Medical Journal 320 18 March pp. 768-770, (p.68).

"Although we cannot change the aspects of human cognition that cause us to err, we can design systems that reduce error and make them safer for patients."
"Systems can be designed to help prevent errors, to make them detectable so they can be intercepted, and to provide means of mitigation if they are not intercepted."
Source: Nolan TW (2000) System changes to improve patient safety British Medical Journal 320 18 March pp.771-773, (p.771).

Violations

"A situation where a person deliberately carries out an action that is contrary to some rule which is organizationally required, such as an approved operating procedure."
Source: Stranks J (2007) Human factors and behavioural safety. Amsterdam: Elsevier p.460.