Action Steps - A specific change that can be made in the system for which researchers expect a specific outcome. Researchers use action steps to experimentally modify a small area of the system in such a way that they anticipate measurable improvement that can be applied to larger areas.
Adverse Drug Events (ADEs) - Any of a myriad of outcomes not intended from use of a drug. These may include errors in medication administration or prescription, but they could also include allergic reactions and unanticipated side effects.
Adverse Event - An injury that was caused by medical management and that results in measurable disability. (definition courtesy the Quality Interagency Coordination Task Force)
Anticoagulants - A type of medication used to "thin" the blood to help prevent heart attack and stroke. Patients are often on these medications for extended periods of time to treat chronic conditions. (ex.: Coumadin)
Brown Bag Medication Review - A service whereby a patient takes all his/her medications to a health care provider (i.e., pharmacist, physician, etc.) and the provider evaluates the interactions of all the medications. This process is designed to "catch" medications that interact that were not formerly recorded and medications that may be redundant.
CQI - Continuous Quality Improvement. A model for reducing defects in a system that affects an outcome of quality.
Culture - A test done in a laboratory to identify a microorganism infecting a patient.
Culture of Safety - The utopian environment where medical errors do not occur because everyone is safety-conscious enough to avoid all mistakes.
Digoxin - A heart medication that must be carefully monitored and controlled. Patients must routinely have blood tests done to monitor blood drug levels.
Diuretics - A type of medication used to remove fluid from the body. Patients are often on these medications for extended periods of time to treat chronic conditions. (ex.: Lasix)
Error - The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems. (definition courtesy the Quality Interagency Coordination Task Force)
Evidence-based Action - Action is the crucial goal of the patient safety program, but the focus of IDPH patient safety is assuring that action taken is based on research evidence.
Focus Groups - A meeting of a specific contingent of a population with researchers with the objective of gaining insight from a given perspective. For example, the IDPH research focus groups consisted of a population sample (i.e., doctors) and several researchers. Researchers ask specific questions intended to foster discussion among participants. Focus group meetings are recorded and later, ideas that were uncovered are used as a starting point for further investigation.
ICU - Intensive Care Unit. The ward in the hospital where very ill patients are monitored very closely. Typically, the patient-staff ratio is very low and the life-saving equipment used is very advanced.
MAE - Medication Administration Error. Specificially, an error in the administration of a drug, either in dose, timing, patient identification, or drug identification.
Medical Error - An adverse event or near miss that is preventable with the current state of medical knowledge. (definition courtesy the Quality Interagency Coordination Task Force)
MRSA - Methicillin Resistant Staphlococcus Aureus. An antibiotic-resistant infection often acquired in hospitals.
Near Miss - An event or situation that could have resulted in an accident, injury or illness, but did not, either by chance or through timely intervention. (definition courtesy the Quality Interagency Coordination Task Force)
Nosocomial Infections - Illnesses acquired in the hospital inpatient environment not resulting from the reasons the patient was admitted (i.e., hospital-acquired pneumonia, etc.)
Patient Safety - This concept has many different operational definitions--each being defined by research context. In general, however, patient safety refers to the concept that patients in health care settings are achieving intended outcomes. This term is often applied to falls, medication errors, and sometimes even more far-reaching concepts such as patient education, etc.
Patient-Provider Interface - The historical treatment of patient safety issues. Analysis of the patient-provider interface assumes that medical errors can be avoided if doctors and patients are more effective. IDPH research assumes that the greatest benefit can be attained by focusing instead on the system perspective.
Provider - Any health care professional who, by the nature of their professional responsibilities, affect the safety of patients. This term usually refers to doctors, nurses, pharmacists, and other clinical personnel.
Resistant Organisms - Microorganisms that have become resistant to the use of common antimicrobials to kill them. This problem is becoming more serious as more bacteria are failing to respond to traditionally very effective antibiotics. Due to the acuity and severity of illness in the hospital, the development of resistant-type organisms is a very frightening reality.
Sentinel Event - A term used by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to describe a serious medical error, including medication errors with serious consequences, suicide, unauthorized departure, wrong-site or wrong-patient surgery, intrapartum maternal death, violent crime committed against a patient, severe patient fall, or hemolytic blood transfusion. For more information, visit the JCAHO web site.
Susceptibility Test - A test done in a laboratory to determine which medication will work best in killing a microorganism infecting a patient.
System - A regularly interacting or interdependent group of items forming a unified whole. (definition courtesy the Quality Interagency Coordination Task Force)
Systems Error - An error that is not the result of an individual’s actions, but the predictable outcome of a series of actions and factors that comprise a diagnostic or treatment process. (definition courtesy the Quality Interagency Coordination Task Force)
Third-Party Payer - An individual or organization who fund health care for another. This term most often applies to HMOs and insurance companies, which directly pay for medical care for their members from premiums paid to them.
Unpreventable Adverse Event - An adverse event resulting from a complication that cannot be prevented given the current state of knowledge. (definition courtesy the Quality Interagency Coordination Task Force)
Voluntary Reporting - The practice of recognizing medical errors through a form that is completed by the individual noticing the error. Often, this process requires those who err to report that they have made mistakes.
VRE - Vancomycin Resistant Enterococcus. An antibiotic-resistant infection often acquired in hospitals.
