Patient Safety Glossary*

“Patient Safety Is The Critical First Step In Enhancing Patient Care”

Patient safety

Freedom from accidental injury or harm; ensuring patient safety involves establishing operational systems and processes that minimize the likelihood of errors and maximizes the likelihood of intercepting them when they occur.

Adverse event

A harm resulting from a medical intervention, the harm is not due to the underlying medical condition of the patient. 

    Preventable adverse event

An adverse event that was attributable to a medical or medication error.

Negligent adverse events

A subset of preventable adverse events that satisfy legal criteria used in determining negligence: whether the care provided failed to meet the standard of care reasonably expected of an average physician qualified to take care of the patient in question.

Error

The failure to complete a planned action as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems.

Medical errors

Any preventable event that may cause or lead to patient harm while under the care of the healthcare professional.  Types of medical errors include:

    Diagnostic errors are exemplified by:

   Error or delay in diagnosis

   Failure to use indicated tests/assessments

   Use of outmoded tests or therapy

   Failure to act on results of monitoring or testing

    Treatment errors are exemplified by:

          Error in the performance of an operation, procedure, or test

          Error in administering the treatment

          Error in the dose or method of using a drug

          Avoidable delay in treatment or in responding to an abnormal test

          Inappropriate/not indicated care

Prevention errors are exemplified by:

Failure to provide prophylactic treatment

          Inadequate monitoring or follow-up of treatment

Other errors are exemplified by:

          Failure of communication

          Equipment failure

          Other system failure

Medication error

Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Medication errors can occur at any stage of medication administration. These include:

    Ordering- Wrong dose, wrong choice of drug

    Transcribing- Wrong frequency of drug administration, missed dose because medication is

     not transcribed

    Dispensing- Drug not sent in time to be administered at the time ordered, wrong drug, wrong

    dose.

Administering- Wrong dose of drug administered, wrong technique used to administer the drug

    Monitoring- Not noting the effects of the given medication.

Adverse Drug Event (ADE)

An ADE is any harm resulting from a medical intervention resulting from a medical intervention related to a drug. ADE’s are typically due to process breakdowns.

ADR

Adverse Drug Reaction occurs when a patient experiences an unfavorable or unanticipated response to medication that had been prescribed, dispensed and administered correctly

Near-miss

An event or situation, in the patient care environment, that could have resulted in a patient injury or visitor incident, but did not, either by chance or through timely intervention.  A near miss can
become a trigger for deep learning and system improvement.

Unanticipated outcome- A negative response to an appropriately provided medical intervention.

System failure- Medical/medication errors that result from the existing organization of the health care delivery system and the way that resources are provided to the delivery system. 

Most patient safety issues are systems related and not attributable to negligence or misconduct.  The key to reducing medical errors is to focus on improving the systems of care and not to blame individuals.