To Err Is Human: Building a Safer Health System (2000)
Chapter: B Glossary and Acronyms
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B—
Glossary and Acronyms
Glossary
Accident—An event that involves damage to a defined system that disrupts the ongoing or future output of the system.1
Active error—An error that occurs at the level of the frontline operator and whose effects are felt almost immediately.2
Adverse event—An injury resulting from a medical intervention.3
Bad outcome—Failure to achieve a desired outcome of care.
Error—Failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim; the accumulation of errors results in accidents.
Health care organization—Entity that provides, coordinates, and/or insures health and medical services for people.
Human factors—Study of the interrelationships between humans, the tools they use, and the environment in which they live and work.4
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.
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Medical technology—Techniques, drugs, equipment, and procedures used by health care professionals in delivering medical care to individuals and the systems within which such care is delivered.5
Micro-system—Organizational unit built around the definition of repeatable core service competencies. Elements of a micro-system include (1) a core team of health care professionals, (2) a defined population of patients, (3) carefully designed work processes, and (4) an environment capable of linking information on all aspects of work and patient or population outcomes to support ongoing evaluation of performance.
Patient safety—Freedom from accidental injury; ensuring patient safety involves the establishment of operational systems and processes that minimize the likelihood of errors and maximizes the likelihood of intercepting them when they occur.
Quality of care—Degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.6
Standard—A minimum level of acceptable performance or results or excellent levels of performance or the range of acceptable performance or results.7 The American Society for Testing and Materials (ASTM) defines six types of standards:
1. Standard test methods—a procedure for identifying, measuring, and evaluating a material, product or system.
2. Standard specification—a statement of a set of requirements to be satisfied and the procedures for determining whether each of the requirements is satisfied.
3. Standard practice—a procedure for performing one or more specific operations or functions.
4. Standard terminology—a document comprising terms, definitions, descriptions, explanations, abbreviations, or acronyms.
5. Standard guide—a series of options or instructions that do not recommend a specific course of action.
6. Standard classification—a systematic arrangement or division of products, systems, or services into groups based on similar characteristics.8
System—Set of interdependent elements interacting to achieve a common aim. These elements may be both human and nonhuman (equipment, technologies, etc.).
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Acronyms
ABMS
American Board of Medical Specialties
ADE
adverse drug event
AERS
Adverse Event Reporting System
AHRQ
Agency for Healthcare Research and Quality
AMA
American Medical Association
AMAP
American Medical Accreditation Program
ASHP
American Society of Health-System Pharmacists
ASRS
Aviation Safety Reporting System
ASTM
American Society for Testing and Materials
CABG
coronary artery bypass graft
CAHPS
Consumer Assessment of Health Plans
CDC
Centers for Disease Control
CEO
chief executive officer
CERT
Centers for Education and Research in Therapeutics
DRG
diagnosis-related group
FAA
Federal Aviation Administration
FDA
Food and Drug Administration
HCFA
Health Care Financing Administration
HEDIS
Health Plan Employer Data and Information Set
HIPAA
Health Insurance Portability and Accountability Act of 1996
HMO
health maintenance organization
HRSA
Health Resources and Services Administration
ICU
intensive care unit
ISMP
Institute for Safe Medication Practices
IV
intravenous
JCAHO
Joint Commission on Accreditation of Healthcare Organizations
MAR
Medical Administration Record
MER
Medical Error Reporting (system)
MERS-TM
Medical Event-Reporting System for Transfusion Medicine
M&M
morbidity and mortality
NASA
National Aeronautics and Space Administration
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NCC-MERP
National Coordinating Council for Medication Error Reporting and Prevention
NCQA
National Committee for Quality Assurance
NIH
National Institutes of Health
NIOSH
National Institute for Occupational Safety and Health
NORA
National Occupational Research Agenda
NPSF
National Patient Safety Foundation
NTSB
National Transportation Safety Board
OPDRA
Office of Post-Marketing Drug Risk Assessment
OSHA
Occupational Safety and Health Administration
PICU
pediatric intensive care unit
POS
point of service
PPO
preferred provider organization
PRO
peer review organization
QIO
Quality Improvement Organization
QuIC
Quality Interagency Coordinating Committee
USP
U.S. Pharmacopeia
VHA
Veterans Health Administration
References
1. Perrow, Charles. Normal Accidents. New York: Basic Books; 1984.
2. Reason, James T. Human Error. Cambridge, MA: Cambridge University Press; 1990.
3. Bates, David W.; Spell, Nathan; Cullen, David J., et al. The Costs of Adverse Drug Events in Hospitalized Patients. JAMA. 277:307–311, 1997.
4. Weinger, Matthew B.; Pantiskas, Carl; Wiklund, Michael, et al. Incorporating Human Factors into the Design of Medical Devices. JAMA. 280(17): 1484, 1998.
5. Institute of Medicine. Assessing Medical Technologies. Washington, DC: National Academy Press; 1985.
6. Institute of Medicine. Medicare: A Strategy for Quality Assurance, Volume II. Washington, DC: National Academy Press; 1990.
7. Institute of Medicine, 1990.
8. American Society for Testing and Materials, www.astm.org/FAQ/3.html.
