Patient Safety And Harm Free Care
Expert-defined terms from the Advanced Skill Certificate in Quality Assurance and Improvement in Health and Social Care course at LearnUNI. Free to read, free to share, paired with a professional course.
Adverse Event – an incident that results in harm to a patient, ranging fr… #
Related terms: incident, near miss. Example: a medication error causing an allergic reaction. Practical application includes tracking through incident reporting systems to identify patterns. Challenges involve under‑reporting due to fear of blame.
Alarm Fatigue – desensitisation of staff to safety alarms caused by exces… #
Related terms: clinical alarm, alert overload. Example: nurses ignoring bedside monitor alarms after frequent false positives. Reducing unnecessary alarms and setting appropriate thresholds are key strategies. Overcoming cultural reliance on alarms can be difficult.
Audit – systematic review of processes or outcomes against established st… #
Related terms: clinical audit, quality audit. Example: reviewing surgical site infection rates against national benchmarks. Audits drive improvement by highlighting gaps. Maintaining staff engagement and data accuracy are common obstacles.
Barrier Analysis – examination of obstacles that prevent safe practice #
Related terms: root cause analysis, systems thinking. Example: identifying lack of equipment availability as a barrier to hand hygiene. Applying barrier analysis helps design realistic interventions. Challenges include distinguishing between perceived and actual barriers.
Best Practice – interventions proven through research to achieve optimal… #
Related terms: evidence‑based practice, clinical guideline. Example: using chlorhexidine for skin antisepsis before catheter insertion. Implementing best practice requires training and monitoring. Resistance to change may impede adoption.
Blame Culture – environment where individuals are held personally respons… #
Related terms: just culture, safety culture. Example: punitive response to medication errors discourages reporting. Shifting to a non‑punitive approach encourages transparency. Overcoming entrenched attitudes is a major challenge.
Case Review – detailed examination of a specific patient incident to unde… #
Related terms: mortality review, morbidity review. Example: multidisciplinary review of a postoperative hemorrhage. Findings inform policy updates. Ensuring objective analysis can be difficult.
Clinical Governance – framework through which organisations are accountab… #
Related terms: quality assurance, risk management. Example: integrating patient safety metrics into board meetings. Supports systematic improvement. Aligning governance with frontline practice may be complex.
Clinical Indicator – measurable element of care that reflects quality or… #
Related terms: performance metric, key performance indicator. Example: proportion of patients receiving prophylactic antibiotics within one hour of incision. Indicators guide benchmarking. Selecting relevant, actionable indicators is essential.
Clinical Pathway – evidence‑based, multidisciplinary plan outlining optim… #
Related terms: care pathway, protocol. Example: fast‑track recovery pathway for hip replacement. Improves consistency and reduces variation. Customising pathways to local context can be challenging.
Communication Failure – breakdown in information exchange that jeopardise… #
Related terms: handover error, information loss. Example: missing critical lab result during shift change. Implementing structured handover tools mitigates risk. Cultural barriers to open communication persist.
Compliance – degree to which practices adhere to standards, policies, or… #
Related terms: adherence, conformity. Example: audit of hand hygiene compliance showing 85 % adherence. Monitoring compliance drives accountability. Achieving high compliance often requires sustained education.
Continuous Improvement – ongoing effort to enhance processes, outcomes, a… #
Related terms: quality improvement, Kaizen. Example: Plan‑Do‑Study‑Act cycles to reduce catheter‑associated infections. Encourages incremental change. Maintaining momentum over time can be demanding.
Data Integrity – accuracy, completeness, and reliability of information u… #
Related terms: data quality, information governance. Example: ensuring electronic medication records reflect actual administration. High data integrity supports valid conclusions. Data entry errors and system incompatibilities threaten integrity.
Defensive Medicine – practice of ordering unnecessary tests or procedures… #
Related terms: over‑testing, risk aversion. Example: ordering CT scans for low‑risk headache. Increases cost and potential harm. Balancing patient safety with prudent resource use is a challenge.
Diagnostic Error – failure to correctly or timely identify a patient’s co… #
Related terms: misdiagnosis, delayed diagnosis. Example: missing sepsis in an elderly patient presenting with atypical symptoms. Implementing decision support tools can reduce errors. Cognitive biases often underlie diagnostic mistakes.
Discharge Planning – coordinated process ensuring safe transition from ho… #
Related terms: care transition, continuity of care. Example: arranging community nursing support for a patient with a new wound. Effective planning reduces readmissions. Communication gaps between settings are frequent obstacles.
Do‑Not‑Resuscitate (DNR) Order – directive indicating that cardiopulmonar… #
Related terms: advanced directive, end‑of‑life care. Example: documenting patient wishes after a thorough discussion. Clear DNR policies prevent unwanted interventions. Misunderstanding of DNR scope can cause conflict.
Education and Training – systematic programmes to develop competencies in… #
Related terms: learning, competency development. Example: simulation‑based training for rapid response. Ongoing education sustains skill levels. Time constraints and staff turnover hinder consistent training.
Emergency Department (ED) Overcrowding – situation where patient demand e… #
Related terms: access block, boarding. Example: prolonged wait times leading to delayed antibiotics for sepsis. Strategies include fast‑track pathways and resource reallocation. Systemic pressures often limit effectiveness.
Equipment Failure – malfunction of medical devices that can cause patient… #
Related terms: device safety, maintenance. Example: infusion pump delivering incorrect dose due to software glitch. Robust maintenance schedules and reporting mechanisms reduce risk. Budget constraints may delay repairs.
Evidence‑Based Practice (EBP) – integration of best research evidence wit… #
Related terms: research utilisation, guideline implementation. Example: using low‑dose aspirin for secondary prevention of cardiovascular events. EBP improves outcomes and standardises care. Translating evidence into practice can be slow.
Feedback Loop – process where information about performance is returned t… #
Related terms: performance feedback, continuous learning. Example: providing clinicians with infection rate dashboards. Timely feedback encourages corrective action. Delayed feedback diminishes impact.
Fire Safety – measures to prevent, detect, and respond to fire hazards in… #
Related terms: evacuation plan, risk assessment. Example: regular fire drills and maintaining clear exit routes. Fire safety protects both patients and staff. Balancing infection control with fire‑safety requirements can be tricky.
FMEA (Failure Modes and Effects Analysis) – proactive method to identify… #
Related terms: prospective risk assessment, reliability engineering. Example: analysing medication administration steps to spot omission risks. FMEA guides preventive redesign. Requires multidisciplinary participation and time.
Hand Hygiene – practice of cleaning hands to remove pathogens and prevent… #
Related terms: infection control, WHO “Five Moments”. Example: using alcohol‑based hand rub before patient contact. Hand hygiene is a cornerstone of patient safety. Compliance often falls short despite education.
Harm‑Free Care – delivery of health services without causing injury, infe… #
Related terms: patient safety, zero‑harm. Example: implementing a bundle to prevent ventilator‑associated pneumonia. The goal is to eliminate preventable harm. Achieving zero harm is aspirational and requires system‑wide commitment.
Health Information Exchange (HIE) – electronic sharing of health data acr… #
Related terms: interoperability, data sharing. Example: accessing a patient’s medication list from a different hospital. HIE supports safer prescribing. Privacy concerns and technical standards pose challenges.
High‑Reliability Organisation (HRO) – entity that operates in complex, hi… #
Related terms: resilience, safety culture. Example: a trauma centre that consistently avoids catastrophic failures. HRO principles include preoccupation with failure and deference to expertise. Embedding these principles requires deep cultural change.
Incident Reporting – systematic capture of events that could or did resul… #
Related terms: adverse event reporting, safety reporting system. Example: using an online portal to log a medication error. Reporting provides data for trend analysis. Under‑reporting remains a major barrier.
Infection Control – set of practices to prevent spread of infectious agen… #
Related terms: sterilisation, isolation precautions. Example: using contact precautions for patients with MRSA. Effective infection control reduces HAIs. Compliance with protocols varies across units.
Interdisciplinary Team (IDT) – group of professionals from diverse discip… #
Related terms: multidisciplinary team, team-based care. Example: nurses, physicians, pharmacists, and social workers planning discharge. IDTs improve communication and safety. Scheduling and role clarity can be problematic.
International Patient Safety Goals (IPSG) – set of objectives by the Join… #
Related terms: global standards, accreditation. Example: goal to identify patients correctly before procedures. Adoption of IPSG promotes uniform safety priorities. Local adaptation may be needed.
JCAHO (Joint Commission on Accreditation of Healthcare Organizations) – U… #
Related terms: accreditation, sentinel event. Example: compliance with National Patient Safety Goals. Accreditation drives systematic safety improvements. Maintaining compliance requires continuous effort.
Kaizen – Japanese term meaning “continuous improvement,” applied to small… #
Related terms: lean, quality improvement. Example: daily huddles to identify workflow bottlenecks. Kaizen fosters staff ownership of safety. Sustaining momentum may be difficult without leadership support.
Knowledge Management – processes for creating, sharing, using, and retain… #
Related terms: learning organisation, best practice repository. Example: an online library of safety protocols. Effective knowledge management accelerates improvement. Information overload can hinder usefulness.
Learning Health System – system that continuously and systematically inte… #
Related terms: real‑world evidence, feedback loop. Example: using electronic health record data to refine sepsis pathways. Enables rapid cycle improvement. Requires robust data analytics capability.
Leadership Walkrounds – senior leaders regularly visit clinical areas to… #
Related terms: executive presence, safety climate. Example: a director meeting nurses on a ward to discuss medication safety. Walkrounds build trust and surface hidden issues. Time constraints limit frequency.
Lean Methodology – approach focused on eliminating waste and improving fl… #
Related terms: value stream mapping, Kaizen. Example: streamlining medication dispensing to reduce waiting time. Lean tools support safety by simplifying processes. Misapplication can lead to staff fatigue.
Learning Curve – representation of how proficiency improves with practice… #
Related terms: skill acquisition, competency development. Example: nurses mastering a new infusion pump after several uses. Understanding the learning curve informs training schedules. Accelerated adoption may increase error risk.
Medication Reconciliation – process of creating an accurate list of a pat… #
Related terms: medication review, discharge planning. Example: verifying home drugs against hospital orders at admission. Reduces drug‑related problems. Incomplete histories often impede reconciliation.
Micro‑learning – short, focused educational modules targeting specific sa… #
Related terms: e‑learning, just‑in‑time training. Example: a 5‑minute video on proper needle disposal. Increases knowledge retention. Limited depth may require supplemental training.
Near Miss – event that could have caused harm but did not, either by chan… #
Related terms: close call, sentinel event. Example: a syringe left uncapped but caught before use. Near‑miss reporting uncovers system weaknesses. Fear of repercussions often suppresses reporting.
Non‑Compliance – failure to follow established policies or standards #
Related terms: deviation, breach. Example: staff bypassing hand‑washing protocols. Identifying non‑compliance triggers corrective actions. Persistent non‑compliance may indicate deeper cultural issues.
Observation Study – research method involving direct monitoring of practi… #
Related terms: audit, ethnography. Example: observing hand‑hygiene adherence during ward rounds. Provides real‑time insight into practice gaps. Observer effect can alter behaviour.
Open Disclosure – transparent communication with patients and families ab… #
Related terms: apology, patient communication. Example: informing a patient about a surgical site infection caused by a breach in sterility. Builds trust and may reduce litigation. Requires skilled communication training.
Organisational Learning – collective process by which an institution gain… #
Related terms: knowledge management, continuous improvement. Example: using lessons from a medication error to redesign the prescribing workflow. Learning loops close gaps. Institutional inertia can impede progress.
Patient‑Centred Care – approach that respects and responds to individual… #
Related terms: shared decision‑making, person‑focused care. Example: involving the patient in selecting an anticoagulant based on lifestyle. Enhances safety by aligning treatment with patient context. Requires effective communication skills.
Patient Safety Indicator (PSI) – metric derived from administrative data… #
Related terms: quality metric, benchmark. Example: rate of postoperative pulmonary embolism. PSIs help compare performance across institutions. Coding inaccuracies can distort results.
Patient Safety Culture Survey – questionnaire used to assess staff percep… #
Related terms: safety climate, organisational assessment. Example: the AHRQ Hospital Survey on Patient Safety Culture. Results guide targeted interventions. Low response rates may limit validity.
Patient Safety Incident – any event or circumstance that could have resul… #
Related terms: adverse event, near miss. Example: a mis‑labelled specimen leading to an incorrect diagnosis. Incident analysis uncovers root causes. Timely reporting is critical.
Patient Safety Officer (PSO) – designated individual responsible for over… #
Related terms: clinical risk manager, quality director. Example: PSO leading a root‑cause analysis team after a sentinel event. PSOs coordinate cross‑departmental safety efforts. Role clarity and authority affect effectiveness.
Patient Safety Net – framework of policies and programmes ensuring vulner… #
Related terms: equity, access to care. Example: community outreach to reduce medication errors among the elderly. Addresses disparities that affect safety. Funding and resource allocation are persistent challenges.
Patient‑Reported Outcome Measures (PROMs) – tools that capture patients’… #
Related terms: patient experience, quality of life. Example: using PROMs to assess pain after joint replacement. PROMs inform safety by highlighting unanticipated adverse effects. Data collection burden can limit uptake.
Performance Dashboard – visual display of key safety metrics for rapid mo… #
Related terms: scorecard, KPI. Example: a real‑time chart showing hand‑hygiene compliance rates. Dashboards promote accountability and quick response. Over‑reliance on numbers may overlook qualitative issues.
Plan‑Do‑Study‑Act (PDSA) Cycle – iterative method for testing changes on… #
Related terms: quality improvement, rapid cycle testing. Example: testing a new checklist for central line insertion on one ward. Allows learning from failures. Poorly defined measures can limit learning.
Practice Variation – differences in care delivery that are not explained… #
Related terms: clinical variation, unwarranted variation. Example: differing rates of imaging for low‑back pain across hospitals. Identifying variation highlights opportunities for standardisation. Resistance may arise from perceived loss of autonomy.
Process Mapping – visual representation of steps in a workflow to identif… #
Related terms: flowchart, value stream mapping. Example: mapping the medication ordering process to locate duplication. Helps target improvement interventions. Complex processes may produce overwhelming diagrams.
Quality Assurance (QA) – systematic activities to ensure that services me… #
Related terms: quality control, quality improvement. Example: routine audit of surgical checklist completion. QA maintains baseline performance. It may be perceived as punitive if not balanced with improvement focus.
Quality Improvement (QI) – coordinated activities aimed at enhancing the… #
Related terms: continuous improvement, PDSA. Example: reducing central line‑associated bloodstream infections through a bundled approach. QI fosters a proactive safety mindset. Sustaining gains after the project ends is often challenging.
Root Cause Analysis (RCA) – systematic investigation to determine underly… #
Related terms: causal analysis, systems thinking. Example: RCA of a fall reveals inadequate lighting and staff fatigue. RCA informs corrective actions that target system flaws. Time‑intensive nature can delay remediation.
Safety Briefing – short, focused meeting before a shift to discuss safety… #
Related terms: huddle, safety huddle. Example: reviewing medication safety alerts at the start of the day. Briefings align staff on immediate risks. Inconsistent attendance reduces effectiveness.
Safety Indicator – specific measure that signals performance in a safety… #
Related terms: metric, KPI. Example: rate of falls per 1,000 patient days. Indicators guide monitoring and benchmarking. Selecting meaningful indicators avoids data overload.
Safety Netting – practice of providing patients with information on what… #
Related terms: post‑discharge advice, follow‑up. Example: giving a patient a written plan for recognizing infection signs after surgery. Enhances early detection of complications. Documentation and consistency can be problematic.
Safety Officer – individual tasked with overseeing risk management and sa… #
Related terms: clinical risk manager, PSO. Example: a safety officer coordinating a medication safety committee. Provides focal point for safety concerns. Role overlap may cause confusion.
Safety Reporting System – electronic platform for logging incidents, near… #
Related terms: incident reporting, adverse event database. Example: a web‑based portal where staff submit medication errors. Facilitates data aggregation for trend analysis. User‑friendliness influences reporting rates.
Safety Training – educational activities designed to improve competence i… #
Related terms: simulation, competency assessment. Example: a workshop on proper use of restraints. Training updates knowledge and skills. Retention declines without reinforcement.
Safety‑Critical Equipment – devices whose failure could directly cause pa… #
Related terms: medical device, high‑risk equipment. Example: ventilators, infusion pumps. Rigorous maintenance and calibration are mandatory. Budget limitations may affect service contracts.
Sentinel Event – unexpected occurrence involving death or serious physica… #
Related terms: critical incident, catastrophic event. Example: surgery on the wrong site. Mandatory reporting triggers immediate investigation. High emotional impact can affect staff morale.
Simulation‑Based Learning – use of realistic scenarios to develop skills… #
Related terms: clinical simulation, skills lab. Example: mock code drills to practice resuscitation. Enhances preparedness and teamwork. Resource‑intensive setup may limit frequency.
Standardised Protocol – written, evidence‑based instructions that guide s… #
Related terms: clinical pathway, guideline. Example: a protocol for sepsis identification and management. Reduces variation and errors. Rigid protocols may not fit every clinical nuance.
Systemic Risk – hazards embedded in organisational structures, processes,… #
Related terms: latent error, system failure. Example: fragmented communication channels across departments. Addressing systemic risk requires organisational change. Identification can be complex.
TeamSTEPPS – evidence‑based framework for improving teamwork and communic… #
Related terms: crew resource management, interdisciplinary collaboration. Example: using the SBAR (Situation, Background, Assessment, Recommendation) technique during handovers. Enhances shared mental models. Training uptake varies across units.
Therapeutic Inertia – failure to initiate or intensify therapy when indic… #
Related terms: clinical inertia, under‑treatment. Example: not escalating antihypertensive therapy despite uncontrolled blood pressure. Recognising inertia prompts guideline‑driven action. Provider complacency can sustain inertia.
Time‑Out Procedure – mandatory pause before invasive procedures to verify… #
Related terms: pre‑procedure checklist, surgical pause. Example: surgical team confirming the correct limb for amputation. Time‑out reduces wrong‑site surgery. Compliance may slip under time pressure.
Training Needs Assessment – systematic evaluation of staff competencies t… #
Related terms: skill audit, learning gap analysis. Example: surveying nurses on their confidence in using electronic medication administration records. Informs targeted education programmes. Survey fatigue can affect response quality.
Transparency – openness in sharing information about safety performance,… #
Related terms: open disclosure, accountability. Example: publishing quarterly safety dashboards for all staff. Promotes trust and collective responsibility. Balancing transparency with confidentiality is delicate.
Turnaround Time (TAT) – interval between a request and the completion of… #
Related terms: process efficiency, lead time. Example: time from lab test order to result availability. Reducing TAT can prevent delays in diagnosis. Bottlenecks often arise in high‑volume settings.
Unintended Consequence – outcome that is not foreseen and may be harmful,… #
Related terms: spillover effect, negative externality. Example: implementing a strict hand‑off protocol that inadvertently increases documentation burden and errors. Anticipating consequences requires thorough planning. Continuous monitoring can detect emerging issues.
Usability Testing – evaluation of how easily users can interact with a sy… #
Related terms: human factors, user‑centered design. Example: testing an electronic prescribing interface for navigation errors. Improves safety by reducing user errors. Limited resources may restrict extensive testing.
Vigilance – sustained attention to potential safety threats and emerging… #
Related terms: monitoring, situational awareness. Example: staff remaining alert for signs of patient deterioration. Cultivates proactive risk identification. Fatigue and workload can erode vigilance.
Virtual Care Safety – considerations ensuring patient safety in telehealt… #
Related terms: e‑health, digital health safety. Example: verifying patient identity before a virtual consultation. Addresses unique risks such as technology failures. Regulatory guidance is still evolving.
Wound Care Bundle – set of evidence‑based practices applied together to r… #
Related terms: care bundle, infection control. Example: using sterile technique, appropriate dressing, and prophylactic antibiotics for surgical wounds. Bundles improve outcomes when adhered to. Compliance monitoring is essential.
Zero‑Harm Initiative – strategic effort to eliminate preventable patient… #
Related terms: harm‑free care, safety culture. Example: organisation-wide campaign targeting medication errors, falls, and pressure injuries. Ambitious goal that drives system‑wide change. Requires sustained leadership commitment and measurement.