Patient safety and human factors: glossary
Keeping up to date with patient safety science is a challenge. It includes many words that need careful explanation.
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.
Some words have more than one interpretation and where this occurs we have included more than one definition.
We provide a separate list describing tools and interventions. The tools currently identified by this resource are listed in the Index to tools and interventions.
There are links to the sources of the quotations where possible.
The links were last accessed on 25 March 2013. Some of them 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.
"Active failures: these are actions or omissions that are sometimes called ‘unsafe acts’. They are actions by frontline healthcare staff who are in direct contact with patients, and include slips, lapses, mistakes or violations of a procedure, guideline or policy."
Source: National Patient Safety Agency (2004) Seven steps to patient safety: full reference guide, London: NPSA, p.25.
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.
Clinical Human Factors
“Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture, organisation on human behaviour and abilities, and application of that knowledge in clinical settings.”
Source: Dr Ken Catchpole on the Clinical Human Factors Group (CHFG) website – see ‘Our definition ‘ tab.
"Human factors encompass all those factors that can influence people and their behaviour.
In a work context, human factors are the environmental, organisational and job factors, and individual characteristics which influence behaviour at work."
Source: Patient Safety First (2010) 'How to' guide for implementing human factors in healthcare. London: Patient Safety First, p.3.
Ergonomics
"Ergonomics (or human factors) is the scientific discipline concerned with the understanding of the interactions among humans and other elements of a system, and the profession that applies theoretical principles, data and methods to design in order to optimize human well being and overall system."
"Practitioners of ergonomics, ergonomists, contribute to the planning, design and evaluation of tasks, jobs, products, organizations, environments and systems in order to make them compatible with the needs, abilities and limitations of people."
Source: International Ergonomics Association’s Executive Council (2000) IEA Definitions of Ergonomics. In W. Karwowski (ed.), International encyclopedia of ergonomics and human factors, London: Taylor & Francis, pp. 102.
Errors
"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.
"An error is defined as the failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve an aim (i.e. error of planning)."
Source: Institute of Medicine (2000) To err is human: Building a safer health system, Washington: National Academies Press, p.27.
Reason identifies two sub-categories of errors: slips, lapses, trips and fumbles are defined as “execution failures”, and mistakes are defined as “planning or problem solving failures." See also Mistake.
Source: Reason J (1995) Understanding adverse events: human factors (PDF 1.97MB), Quality in Health Care, 4(2) June, pp.80-89 (quotes from pp.81 and 88).
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.
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.
Human factors - see Clinical human factors
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-library at 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.
Reason makes the distinction between rule based and knowledge based mistakes:
Rule based mistakes “…relate relate to problems for which the person possesses some prepackaged solution, acquired as the result of training, experience, or the availability of appropriate procedures. The associated errors may come in various forms: the misapplication of a good rule (usually because of a failure to spot the contraindications), the application of a bad rule, or the nonapplication of a good rule."
Knowledge based mistakes “…occur in novel situations where the solution to a problem has to be worked out on the spot without the help of preprogrammed solutions. This entails the use of slow, resource-limited but computationally-powerful conscious reasoning carried out in relation to what is often an inaccurate and incomplete "mental model" of the problem and its possible
causes. Under these circumstances the human mind is subject to several powerful biases, of which the most universal is confirmation bias."
Source: Reason J (1995) Understanding adverse events: human factors (PDF 1.97MB), Quality in Health Care, 4(2) June, pp.80-89 (quotes from pp.81).
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, para 1.
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.
"The avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the processes of health care. These events include “errors,” “deviations,” and “accidents.” Safety emerges from the interaction of the components of the system; it does not reside in a person, device, or department."
Source: National Patient Safety Foundation, Patient safety dictionary N-Z, NPSF website.
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.
Resilience
"A key human factors concept is “resilience,” which investigates how individuals, teams and organisations monitor, adapt to and act on failures in high-risk situations. Although it is a new concept to healthcare, it is well accepted in other high-risk industries.
Resilience moves the focus away from “What went wrong?” to “Why does it go right?”, that is, it moves from simplistic reactions to error making toward valuing a proactive focus on error recovery. Resilience is a better match for healthcare settings than the principles for high reliability because it more effectively addresses the unique complexities of healthcare."
Source: Jeffcott, SA, Ibrahim JE, Cameron PA (2009) Resilience in healthcare and clinical handover, Quality and Safety in Health Care, 18(4) August, pp.256-260 (quotes from p.256). doi:10.1136/qshc.2008.030163.
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
“... it is essentially a culture where staff have a constant and active awareness of the potential for things to go wrong. It is also a culture that is open and fair and one that encourages people to speak up about mistakes. In organisations with a safety culture people are able to learn about what is going wrong and then put things right .”
Source: National Patient Safety Agency (2004) Seven steps to patient safety: full reference guide, London: NPSA, p.18.
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: Building a safer health system, 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, (quote from p.768).
"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, (quote from 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.
Further glossaries
You may also find the following glossaries useful.
Agency for Healthcare Research and Quality Patient Safety Net (PSNet): Glossary
The AHRQ Patient Safety Network is a USA web-based resource "which features the latest news and essential resources on patient safety".
NHS Scotland Quality Improvement Hub: Patient safety glossary of terms
The NHS Scotland Quality Improvement Hub is a national collaboration which aims to support NHS boards with implementation of the Healthcare quality strategy in Scotland. The glossary is in the section of the Hub which supports the delivery of safe care.