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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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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. 210

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211 APPENDIX B 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, des- criptions, explanations, abbreviations, or acronyms. 5. Standard guide—a series of options or instructions that do not re- commend a specific course of action. 6. Standard classification—a systematic arrangement or division of pro- ducts, 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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212 TO ERR IS HUMAN 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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213 APPENDIX B 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.

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