Glossary

Adverse event: “An undesired patient outcome that may or may not be the result of an error.”i

Alcohol-based handrub: “An alcohol-containing preparation (liquid, gel or foam) designed for
application to the hands for hygienic hand antisepsis.”ii

Braden Scale: A tool for assessing a patient’s risk of developing a pressure ulcer. See the
Braden Scale.

Concentrated electrolyte solutions: Medications for parenteral administration including:

potassium chloride (2 mEq/mL), potassium phosphate (3 mMol/mL), sodium chloride
(> 0.9%), and magnesium sulfate (50%).

Contributing Factor: “A circumstance, action or influence which is thought to have played a part
in the origin or development of an incident or to increase the risk of an incident.”iii

Documentation: Written information, including that which is captured digitally, that serves as a
record of nursing assessments, diagnoses, plans, interventions, and evaluations.

Fall: “Loss of upright position that results in landing on the floor, ground or an object or
furniture or a sudden, uncontrolled, unintentional, non-purposeful, downward
displacement of the body to the floor/ground or hitting another object like a chair or
stair.”iv

Hand hygiene: “Any action of hygienic hand antisepsis in order to reduce transient microbial
flora (generally performed either by handrubbing with an alcohol-based formulation or
handwashing with plain or antimicrobial soap and water).”v

Handrub: see Alcohol-based handrub

Handover communication: “Occur anytime there is a transfer of responsibility for a patient from
one caregiver to another. The goal … is to provide timely, accurate information about a
patient’s care plan, treatment, current condition and any recent or anticipated changes.” vi

Harm: “Impairment of structure or function of the body and/or any deleterious effect arising
there from. Harm includes disease, injury, suffering, disability and death.”vii

Health: “A state of complete physical, mental and social wellbeing and not merely the absence
of disease or infirmity.”viii

Health care organization: “Entity that provides, coordinates, and/or insures health and medical
services for people.”ix

Healthcare: “Services received by individuals or communities to promote, maintain, monitor or

restore health.”x

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Health care-associated infection: An infection acquired by the patient while under the care of a
health care organization.

Health care team: A group of individuals from any of the health disciplines that provides
services to the patient.

High-alert medications: Various classes of medications that pose a particularly high risk of
injury if misused.

Identifiers: Data used to ascertain the identity of an individual. Name, birthdate, and medical
record number are examples of proper identifiers. At least two must be used in the
process of patient identification. Neither room number nor bed number are considered
identifiers.

Incident: “An event or circumstance which could have, or did lead to unintended and/or
unnecessary harm to a person, and/or a complaint, loss or damage.”xi

Injection devices: Tools, typically needles and syringes, used for parenteral administration of
medications, vaccines, blood products, and nutrients.

Intervention: “In the broadest sense, the act or fact of interfering so as to favorably modify a
condition.”xii

LASA: see Look-Alike, Sound-Alike Medications

Look-Alike, Sound-Alike Medications: Medications names that look or sound similar such that
there exists a potential for error in administration. Medications that have dissimilar
names but similar appearance/packaging also fall into this category.

Medical history: An account of a patient’s prior and current health status, including prior
medical events, treatments, and responses to these.

Medication error: “An error in the process of ordering, transcribing, dispensing, administering,
or monitoring medications, irrespective of the outcome (i.e., injury to the patient).” xiii

Medication reconciliation: “Unintended inconsistencies in medication regimens occur with any

transition in care. Medication reconciliation refers to the process of avoiding such
inadvertent inconsistencies by reviewing the patient's current medication regimen and
comparing it with the regimen being considered for the new setting of care.”xiv

Medication safety: “Freedom from accidental injury during the course of medication use;
activities to avoid, prevent, or correct adverse drug events which may result from the use
of medications.”xv

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Morse Fall Scale: A tool for assessing a patient’s risk for falling. See Module 7: Fall
Prevention.

Name alert: A written notation, such as a brightly colored sticker on a patient’s chart, intended to
notify the health care team to take extra care in identifying the patient because another
patient with an identical or similar name is also under care. All affected patients must be
so identified. Therefore, if three patients share similar names, all three charts must be
labeled with a name alert.

Norton Scale: A tool for assessing a patient’s risk of developing a pressure ulcer. See Module 8:
Pressure Ulcer Prevention.

Patient: “A person who is a recipient of healthcare”xvi

Patient identification: The process of positively ascertaining the identity of a recipient of health
care.

Patient safety: “The reduction of risk of unnecessary harm associated with healthcare to an
acceptable minimum.”xvii

Pre-procedure verification: A three-step process performed by the health care team prior to the
performance of a procedure and prior to the administration of any anesthetic: 1) the team
verifies the identity of the patient, the procedure to be performed, the site of the
procedure, and if applicable, the implants/prostheses to be used; 2) If applicable, the
procedure site is marked with the assistance of the patient whenever possible; and 3) the
team conducts a “time out,” providing any and all team members the opportunity to voice
concerns about the pre-procedure verification so that these may be resolved in advance of
the start of the procedure.

Pressure ulcer: “A pressure ulcer is localized injury to the skin and/or underlying tissue usually
over a bony prominence, as a result of pressure, or pressure in combination with
shear.”xviii

Preventable: “Accepted by the community as avoidable in the particular set of circumstances.” xix

Quality: “The degree to which health services for individuals and populations increase the
likelihood of desired health outcomes and are consistent with current professional
knowledge.”xx

Risk: “The probability that an incident will occur.”xxi

Risk assessment: “The qualitative or quantitative estimation of the likelihood of (adverse) effects
that may result from exposure to specified events or processes or from the absence of
beneficial influences.”xxii

Safety: “The reduction of risk of unnecessary harm to an acceptable minimum.”xxiii

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SBAR: A technique for systematic communication between caregivers about patient status.
SBAR is a mnemonic for the four components of the communication technique:
Situation, Background, Assessment, and Recommendation.

Surgical safety checklist: An algorithmic listing of actions to be performed prior to surgery, the
goal being to ensure that no step will be forgotten.xxiv

Time out: “A specifically allocated period where no clinical activity is taking place. During this
time, all team members independently verify the impending clinical action.” xxv
Additionally, it is an opportunity for any and all team members to voice concerns about
i
World Health Organization. (2009, January). More than words: Conceptual framework for the international
classification for patient safety, Version 1.1. Retrieved from
http://www.who.int/patientsafety/taxonomy/icps_full_report.pdf
ii
World Health Organization. (2009, August). Hand Hygiene: Why, How & When? Retrieved from
http://www.who.int/gpsc/5may/Hand_Hygiene_Why_How_and_When_Brochure.pdf
iii
World Health Organization. (2009, January). More than words: Conceptual framework for the international
classification for patient safety, Version 1.1. Retrieved from
http://www.who.int/patientsafety/taxonomy/icps_full_report.pdf
iv
U.S. Department of Veterans Affairs (n. d.) Definitions. VHA NCPS Fall Prevention and Management.
Retrieved from http://www.patientsafety.gov/CogAids/FallPrevention/index.html#page=page-12
v
World Health Organization. (2009, August). Hand Hygiene: Why, How & When? Retrieved from
http://www.who.int/gpsc/5may/Hand_Hygiene_Why_How_and_When_Brochure.pdf
vi
Runy, L. A. (2008, May 5). Patient Handoffs. Hospital and Health Networks. Retrieved from
http://www.hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/
05MAY2008/0805HHN_FEA_Gatefold&domain=HHNMAG
vii
World Health Organization. (2009, January). More than words: Conceptual framework for the international
classification for patient safety, Version 1.1. Retrieved from
http://www.who.int/patientsafety/taxonomy/icps_full_report.pdf
viii
ibid.
ix
ibid.
x
ibid.
xi
ibid.
xii
ibid.
xiii
ibid.
xiv
Agency for Healthcare Research and Quality. (n. d.). Medication Reconciliation. Glossary. Retrieved from
http://www.psnet.ahrq.gov/glossary.aspx
xv
World Health Organization. (2009, January). More than words: Conceptual framework for the international
classification for patient safety, Version 1.1. Retrieved from
http://www.who.int/patientsafety/taxonomy/icps_full_report.pdf
xvi
ibid.
xvii
ibid.
xviii
European Pressure Ulcer Advisory Panel. (2010). Pressure Ulcer Prevention Quick Reference Guide. Retrieved
from http://www.epuap.org/guidelines/Final_Quick_Prevention.pdf
xix
World Health Organization. (2009, January). More than words: Conceptual framework for the international
classification for patient safety, Version 1.1. Retrieved from
http://www.who.int/patientsafety/taxonomy/icps_full_report.pdf
xx
ibid.
xxi
ibid.
xxii
ibid.
xxiii
ibid.
xxiv
Definition adapted from: Agency for Healthcare Research and Quality. (n. d.). Checklists. Patient Safety
Primers. Retrieved from http://www.psnet.ahrq.gov/primer.aspx?primerID=14

4
 the pre-procedure verification so that these may be resolved in advance of the start of the
procedure.

Universal Protocol: see Pre-procedure Verification

xxv
World Health Organization. (2007). Patient Safety Solutions-Performance of Correct Procedure at Correct
Body Site. Aide Memoire, Volume 1 (Solution 4). Retrieved from
http://www.who.int/entity/patientsafety/solutions/patientsafety/PS-Solution4.pdf