Current glossary terms sourced directly from Improving America’s Hospitals: The Joint Commission’s Annual Report on Quality and Safety 2013 Glossary


Unplanned, unexpected, and undesired events, usually with one or more adverse consequences.


The obligation to demonstrate, review, and take responsibility for performance, both for the results achieved in light of agreed expectations and for the means used.

ADEs due to opioids (EOM-ADE-111)

Type: Outcome Numerator: Number of patients treated with opioids who received naloxone during the review period. Denominator: Number of patients who received an opioid agent during the review period. Calculator Method: (N/D)*100

adverse drug event

(adverse drug error, ADE), (1)Any incident in which the use of a medication (drug or biologic) at any dose, a medical device, or a special nutritional product (e.g., dietary supplement, infant formula, medical food) may have resulted in an adverse outcome in a patient; (2) An incident resulting from medical intervention related to a drug.

adverse event

(1) An injury that was caused by medical management (rather than the underlying disease) and that prolonged the hospitalization, produced a disability at the time of discharge, or both; (2) An injury resulting from a medical intervention; (3) An untoward, undesirable, and usually unanticipated event, such as death of a patient, an employee, or a visitor in a health care organization. Incidents such as patient falls or improper administration of medications are also considered adverse events even if there is no permanent effect on the patient; (4) An event or omission arising during clinical care and causing physical or psychological injury to a patient; (5) An injury that was caused by medical management and that results in measurable disability.


The goal intended to be attained.

at-risk behavior

Behavioral choice that increases risk where risk is not recognized, or is mistakenly believed to be justified.

best practices

Actions, protocols, or guidelines considered, on the basis of the current state of knowledge n given field, to be the best in their class, having demonstrated effectiveness in carrying out processes or subprocesses. Best practices can be identified inside or outside an organization. The can be stored in electronic repositories for sharing throughout the organization, and thus they can become the nucleus of a knowledge management initiative.


The act by which an effect is produced (also known as “causality”). In epidemiology, the concept of causation is used to relate certain types of influences (predisposing, enabling, precipitating, or reinforcing factors) to the occurrence of disease. The doctrine of causation is important in determining negligence and thus is an important concept in the field of criminal law.


Catheter-associated urinary tract infection.

CAUTI Rate, All Tracked Units (EOM-CAUTI-18)

Type: Outcome: Numerator: Catheter associated urinary tract infections based on CDC (all tracked units). Denominator: Total number of urinary catheter days for all patients that have an indwelling catheter. Calculator Method: (N/D)*1000


Clostridium difficile Infection, also known as C. diff


A tool for ensuring all important steps or actions in an operation have been taken. Checklists contain items important or relevant to an issue or situation. Checklists are often confused with check sheets.


Central line-associated bloodstream infection.


A supportive discussion with the employee on the need to engage in safe behavioral choice.

common-cause variation

Any normal variation inherent in a work process.


Characteristic of systems where nonlinear interactive components, emergent phenomena, continuous and discontinuous change, and unpredictable outcomes are found. Although there is at present no single accepted definition of complexity, the term is applied across a range of different yet related system features, such as chaos, self-organized criticality, adaptivity, neural nets, nonlinear dynamics, and far-from-equilibrium conditions.


The condition of not disclosing identifying information, such as names of the reporter and the patient and location of the incident. In blameless reporting systems, confidentiality is preferred over anonymous reporting so that the reporter can be contacted to provide further information if it is needed.

continuous quality improvement

Ongoing betterment of products, services, and processes through incremental and breakthrough refinements. Sometimes called “continual improvement.”

control chart

A chart with upper and lower control limits on which values of some statistical measure for a series of samples or subgroups are plotted. The chart frequently shows a central line to help detect a trend of plotted values toward either control limit.

crew resource management

A process of training, used in the airline industry, that considers human performance limitations (such as fatigue and stress) and designs countermeasures to combat them (for example, briefings, monitoring and cross-checking, decision making, and review and modification of plans) along with instruction in confronting the authority gradient. Sophisticated simulators allow full crew to practice dealing with accident-inducing situations without jeopardy and to receive feedback on both individual and team performance.

culture of safety

A culture in which safety is the top priority. A culture of safety is characterized by vigilance and by authority based on expertise rather than position. A culture of safety constantly seeks to learn, not only from its failure but also from anticipation of failure and from mental simulations of possible failure scenarios. Transparency of error and failure and an ambience of trust are hallmarks.

disciplinary action

Actions beyond remedial, up to and including punitive action or termination.


The act of informing others that an event has occurred. Disclosure of errors and accident sin a health care setting should include a prompt and compassionate explanation of what is understood about what happened and about the probable effects; information about what is being done to ensure safety; assurances that a full analysis will take place and that the findings of the analysis, as they are known, will be communicated; information about changes that are being made, on the basis of the analytical findings, to reduce the likelihood of a similar event; and an acknowledgement of accountability. When an accident occurs, disclosure to patients and their families is in order.


Differences in the quality of health care not due to access-related factors or clinical needs, preferences, or appropriateness of intervention. Examples may include, but are not limited to, measures that address variation in care related to race, ethnicity, socioeconomic status, sexual orientation, cognitive or physical disabilities, and age.

early elective delivery

A delivery occurring after 37 and before 39 weeks of gestation, without a medical reason.


An act of commission (doing something wrong) or omission (failing to do something right) that reaches the patient and leads to an undesirable outcome or significant potential for such an outcome.

error proofing

Use of process or design features to prevent the acceptance or further processing of nonconforming products. Also known as “mistake proofing.”

error-tolerant culture

A culture or system that accepts errors as a fact of life and creates strategies and work processes designed to mitigate errors. Nevertheless, an error-tolerant culture or system does not accept the violation of formal rules, especially those that have been validated as having strategic value for avoiding or mitigating errors. Same as error-tolerant system.

evidence-based care

Using current best evidence in making decisions about the care of individual patients or in the delivery of health services.

Excessive anticoagulation with warfarin, Inpatients (EOM-ADE-12)

Type: Outcome Numerator: Inpatients with Excessive anticoagulation Denominator: Inpatients receiving anticoagulation therapy Calculator Method: (N/D)*100

Falls With Injury (EOM-FALLS-38)

Type: Outcome Denominator: Number of patient falls with an injury of minor or greater to the patient. A fall is defined as an unplanned descent to the floor. Numerator: Number of patient days including short stay patients, observation patients and same day surgery patients Calculation Method: (N/D)*1000

Falls With or Without Injury (EOM-Falls-37)

Type: Outcome Denominator: Number of patient falls with or without injury to the patient. A fall is defined as an unplanned descent to the floor. Numerator: Number of patient days including short stay patients, observation patients and same day surgery patients Calculation Method: (N/D)*1000


Healthcare-associated infection.


A category of adverse effects that includes a patient’s death, or any temporary or permanent impairment of the patient’s bodily functions or structure that requires medical intervention. Harm stems from system flaws that go unchecked and are allowed to affect a patient.

high-reliability organization

(HRO) Organizations in which the performance of high-risk activities is the norm but rates of accident or harm are low. In HROs, failure is not an option, because lives are at stake. Performance of tasks is highly disciplined, and creating safety is everyone’s practice and first priority. HROs are characterized by communication, training, default hierarchy (that is, in conditions of emerging risk, the basis of decision-making authority moves from rank to technical expertise), continual process auditing, standards that establish quality, reporting, learning, and an ambience of trust.

hindsight bias

Hindsight bias comes into play when human performance is judged I the context of accidents or near misses. Hindsight bias, always present when a situation is evaluated in retrospect, has two aspects: observers of past events exaggerate what others should have been able to foresee, and they are unaware of how much their own perceptions are influenced by their retrospective knowledge of the situation’s outcome.

human error

Inadvertently doing other than what should have been done; a slip, lapse, or mistake.

human factors

A field concerned with understanding and enhancing human performance in the workplace, especially in complex systems. Among this field’s significant contributions to patient safety is the notion that creating safety requires hanging the conditions in which human beings work.

Hypoglycemia in inpatients receiving insulin (EOM-ADE-13)

Type: Outcome Numerator: Hypoglycemia occurrences (inpatient) Denominator: Inpatients receiving insulin therapy Calculator Method: (N/D)*100

just culture

A just culture is one that promotes a questioning attitude, is resistant to complacency, and creates an atmosphere of trust in which people are encouraged (even rewarded) for providing essential information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior. (Marx, 2001)


Errors that result from some sort of failure in the execution or storage phase of an action sequence. Lapses differ from slips in that they are not visible.

learning organization

An organization that continually expands its capacity to create its future by moving beyond adaptive learning *that is, learning enhances the capacity to create). A learning organization is a place where people are continually discovering how they create their reality and how they can change it. In a safety culture, the term denotes an organization that actively pursues continuous learning to create safety, where the goal is to learn from failure as well as from successes. The learning organization that has a safety culture is characterized by seeking information, rewarding messengers, and discovering improvements that lead to far-reaching innovation and change (Senge, 1990).


Deficits or failures in judgment, either in selecting an objective (such as a treatment goal) or in specifying the means to achieve it (such as formulating a treatment plan; see Reason, 1990).


Methicillin-resistant Staphylococcus aureus.


Having many interacting variables that come together to create the conditions for an event. Medical accidents usually result from multiple causes rather than from a single cause.

near miss

An event or situation that might have resulted in an accident, injury, or illness but did not reach the patient, either by chance or through timely intervention (AHRQ Common Formats). Near misses are valuable tools for learning about system vulnerability and resilience.

normalization of deviance

The acceptance of, or failure to recognize, faulty and risk-prone processes, and the minimization of serious deficiencies so that they become familiar, pervasive, and entrenched in the culture of the work environment and are accepted as normal.

outcomes measure

A measure that focuses on the results of the performance or nonperformance of a process. (See process measure.)

patient and family engagement

(cross-cutting area) Engaging patients and families in managing and evaluating their health and health care, and in making decisions about their care. Examples may include, but are not limited to, measures that address if patients are asked for feedback on their experience with care, have access to tools and support systems enabling them to navigate and manage their care, and have access to information, and assistance that enables them to make informed decisions.

patient experience

The sum of all interactions, shaped by an organization's culture, that influence patient perceptions across the continuum of care. (Definition by Beryl Institute)

patient safety

A condition in which patients are protected from harm through error reduction and protective mechanisms to assure that those errors that do occur do not harm the patient. Patient safety is achieved through the disciplined and aggressive creation and maintenance of systems that take account of safety science, accident causation, and human factors.

performance improvement

A movement encompassing a philosophy and attitude dedicated to analyzing the organization’s capabilities and processes and repeatedly making them better in order to achieve the objective of improving the organization itself.


Commonly referred to as PDSA (or PDCA, for plan‐do‐check‐act), refers to the cycle of activities advocated for achieving process or system improvement. The cycle was first proposed by Walter Shewhart, one of the pioneers of statistical process control (see definition for run chart) and popularized by his student, quality expert W. Edwards Deming. The PDSA cycle represents one of the cornerstones of continuous quality improvement (CQI). The components of the cycle are described in more detail in the Quality Improvement Course: QI 102: The Model for Improvement: Your Engine for Change in the Courses section of the IHI Open School.

process failures

Instances of faulty or absent completion of one or more steps in an ordained sequence.

process flow

The orderly progression of a goal-directed series of interrelated actions, events, mechanisms, or steps to achieve a defined outcome. Ordering medication entails a process flow, as does administering anesthesia, points discussed at Institute for Healthcare Improvement National Congress on Reducing Averse Drug Events and Medical Errors, held Mar. 26-27, 1997.

process flow diagram

A pictorial representation that shows all the steps of a process and uses easily recognizable symbols to represent how various steps in a process are related to each other. Also known as a “sequence of events diagram.”

process measure

A measure that focuses on one or more steps that lead to a particular outcome. (See outcomes measure.)

punitive environment

An environment that punishes workers in close proximity to an accident as well as those who report potentially hazardous situations. The Organization with a punitive or retaliatory environment creates an atmosphere where staff members at the sharp end are afraid to disclose failures and near misses. The organization thus eliminates the opportunity to learn from mistakes. Also known as retaliatory environment.

rapid cycle change

A structured methodology of conducting progressive cycles of experimentation based on PDSA cycles of improvement, informed by data and measurements to gauge whether change is achieving desired results.

reckless behavior

Behavioral choice to consciously disregard a substantial and unjustifiable risk.

retaliatory environment

An environment that punishes workers in close proximity to an accident as well as those who report potentially hazardous situations. The Organization with a punitive or retaliatory environment creates an atmosphere where staff members at the sharp end are afraid to disclose failures and near misses. The organization thus eliminates the opportunity to learn from mistakes. Also known as punitive environment.

run chart

A chart showing a line connecting numerous data points collected from a process running over time.

safety science

(patient safety science) An emerging discipline that integrates knowledge from fields outside health care, such as human factors and organizational sociology, as well as lessons from high-reliability organizations, and applies them to the delivery of health care services. Cognitive psychologists, human factors engineers, sociologists, and organizational scientists have contributed to safety science by studying accidents and near misses in aviation, the nuclear power industry, military operations, and, occasionally, health care delivery.


The process by which individuals in organizations take time to understand a complex situation thoroughly before making a decision. By creating understanding and informed action, sensemaking allows managers to deal properly with unforeseen events while they are still issues, before they become problems or crises.

sentinel event

An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation whose occurrence would carry a significant chance o a serious adverse outcome. Such events are labeled “sentinel” because they signal the need for immediate investigation and response.

sharp end

Points of vulnerability in the care delivery system where expertise is applied, and where error is experienced. Health care workers who provide direct patient care are working at the sharp end.


Standardized Infection Ratio.

situational awareness

Vigilance applied to a specific context, such as a dangerous work situation. Situational awareness can be observed in specific behaviors, such as constant communication and eye contact among members of a team as they watch each other, or listening for what is unusual so problems can be rectified before intolerable risk emerges.


Errors that result from some failure in an action’s execution phase or storage phase, or in both phases; the plan guiding the actions may or may not have been adequate to achievement of the desired objective. Examples are slips of the tongue, slips of the pen, and slips of action.

special causes

Causes of variation that arise because of special circumstances. They are not an inherent part of a process. Special causes are also referred to as assignable causes. Also see “common causes.”


The intentional and methodical expansion of the number and type of people, units, or organizations using the improvements. The theory and application comes from the literature on Diffusion of Innovation.


Surgical Site Infection

standard work

A precise description of each work activity, specifying cycle time, takt time, the work sequence of specific tasks and the minimum inventory of parts on hand needed to conduct the activity. All jobs are organized around human motion to create an efficient sequence without waste. Work organized in such a way is called standard(ized) work. The three elements that make up standard work are takt time, working sequence and standard in-process stock.


When policies and common procedures are used to manage processes throughout the system.


In a safety culture, describes a work policy by which any member of a team may stop the action to restore safety if he or she believes that the margin of danger exceeds a team’s ability to manage and recover – or, in other words, when operations appear to be moving into conditions of intolerable risk.

Swiss Cheese Model of Accident Causation

A metaphorical, visual representation of the nature of emerging risks in complex systems characterized by vulnerabilities as well as defenses.


Any collection of components and relations between them, whether or not the components are human, when the components have been brought together for a well-defined goal or purpose.

system errors

Delayed negative consequences of technical design issues or organizational issues and decisions. Also referred to as “latent errors”.

system vulnerabilities

Weaknesses, deficiencies, or flaws in the organization of care delivery. A system vulnerability may be as narrow as a work process or as broad as an ineffective governance function or executive team.

systems approach

An approach to patient safety based on the notion that characteristics of the work system can make hazards both more likely and more difficult to detect and correct. The systems approach take the position that individuals are responsible for the quality of their work, but that focusing on systems rather than on individuals will be more effective in reducing harm. The systems approach substitutes inquiry for blame and focuses on circumstances rather than on character. When an accident occurs, prompt, intensive investigation and multidisciplinary systems analysis are used to discover proximal and systemic causes.


Individuals with expertise and competence assembled to perform work that must be accomplished together. Characteristics include clear roles and responsibilities, expectations, training, reliable communications, and substitutions and flexibility in function.


A small‐scale trial of a new approach or a new process. A test is designed to learn if the change results in improvement and to fine‐tune the change to fit the organization and patients. Tests are carried out using one or more plan‐do‐study‐act (PDSA) cycles.


Openness in the delivery of health care services. When transparency is a feature of a health care delivery system, work processes are made visible, and information is make available to patients and their families so that they can make informed decisions about selecting a health plan, a hospital, a clinical practice, or one of several alternative treatments. The notion of transparency includes providing information about the system’s performance in terms of safety issues, evidence-based practice, and patient satisfaction. The circumstances surrounding accidents are also disclosed.


Ventilator-associated event.


A change in data, characteristic or function caused by one of four factors; special causes, common causes, tampering or structural variation (see individual entries).

zero defects

A performance standard and method Philip B. Crosby developed; states that if people commit themselves to watching details and avoiding errors, they can move closer to the goal of zero defects; often adopted as a standard for performance or a definition of quality (notably in Crosby Quality Training).