Accountable (Accountability) (Ref 9)
Expected to give an account, reason or explanation for one’s own actions to someone.
Adverse event (Ref 5)
An unexpected event related to healthcare management or delivery that a patient/resident directly experiences and that results in no harm, harm or death.
Attribution bias (Ref 19)
Tendency to explain the behaviour of others based on perceived characteristics of the individual (e.g., intelligence, status, personality).
Close call (Ref 1)
An event or series of events that nearly resulted in a patient being harmed but harm was avoided.
(‘Near miss’ is a term used by some organizations but is confusing. See Terms to Avoid.)
Negative conditions imposed on an individual as part of their taking responsibility for their unacceptable actions.
Compliance (Ref 10)
The action or fact of following accepted regulations, policies or standards.
Culture (Organizational culture) (Ref 3)
A set of shared values (what is important), attitudes (way of thinking or feeling about something) and beliefs (how things work) that influence behaviours (how everyone acts).
Culture is often described as ‘the way we do things around here’
Discipline (Sanction) (Ref 11)
The practice of using punishment to correct disobedience to rules or a code of behaviour. Punitive discipline that is documented in the individual’s employment record may include a formal warning or reprimand, suspension or termination of employment or privileges.
A sanction is form of discipline – a threatened penalty for disobeying a law or rule.
Error (Human error) (Ref 6)
The failure to complete a planned action as it was intended, or use of an incorrect plan.
There are three types of error:
- Slip: Failure in attention or perception (e.g., a pharmacy technician fills a prescription with diazepam instead of the intended diltiazem).
- Lapse: Failure in memory (e.g., a nurse forgets to check a blood sugar level on a diabetic patient at the required time).
- Mistake: Failure in the mental processes involved in assessing available information, making a plan, forming intention, or judging the likely consequences of a planned action (e.g., A physician orders a medication the patient is allergic to because he did not check the patient’s allergy status).
Flexible culture (Ref 17)
Organizations with a flexible culture are able to shift power during crises from the top of the bureaucracy to task experts on the spot.
Harm (Ref 4)
An unexpected outcome related to the care and/or services provided to the patient that negatively affects a patient’s health and/or quality of life.
Hazard (Ref 1)
A situation that has potential for harm and does not involve the patient.
Hindsight bias (Ref 15)
Knowledge about the outcome of an event (hindsight) results in unrealistic expectations that those involved should have been able to anticipate what would happen and thus make different decisions.
Human factors (Ref 14)
Knowledge about human abilities, human limitations, and other human characteristics. Human factors can be applied to designing safe systems and to understanding what influenced the choices individuals made when something went wrong.
Informed culture (Ref 17)
Having a safety information system to collect, analyze, and share information from safety incidents and close calls, and doing regular proactive checks on indicators of safety.
Just culture (Ref 17)
An atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information. People are also clear about where the line must be drawn between acceptable and unacceptable behaviour.
Learning culture (Ref 17)
The willingness and ability to draw the right conclusions from a safety information system, and to implement major reforms when needed to improve safety. An organization with a learning culture is called a ‘learning organization’.
Non-compliance/ Non-compliant actions (Violation) (Ref 6)
A deliberate deviation from standards, rules or safe operating procedures.
Non-compliant behaviour (Ref 18)
Short-cuts, workarounds, and deviations from an organization’s procedures that happen gradually over time to cope with the demands of the job. The new behaviours are perceived to be more efficient with little additional risk. Also called ‘behavioural drift’. This is a normal aspect of human behaviour and often happens unconsciously. It can affect one individual or become an acceptable pattern of behaviour within a work unit.
Often referred to as ‘at-risk behaviour’ because these actions typically have a greater probability that something will go wrong.
Outcome (Ref 6)
A product, result or practical effect.
Outcome bias (Ref 15)
Knowledge of the outcome of a situation influences the evaluation of the quality of the decisions made by those who were involved. The greater the severity of the outcome, the more critical the judgement is of the individuals and the decisions they made during the situation.
Patient-provider partnership culture
A set of values, beliefs and practices shared by everyone working in healthcare that enhance patients’ experience by including them in all aspects of the design and delivery of healthcare. In a partnership culture, patients are treated with respect, dignity, compassion and openness. They are actively involved in their care and information about their care is shared openly.
Patient safety (Ref 6)
Reducing and mitigating unsafe acts within the healthcare system and using best practices shown to lead to optimal patient outcomes.
Patient safety incident (Ref 6)
A situation in which a patient is harmed or nearly harmed (close call) by the healthcare they received.
Quadruple Aim (Ref 2)
The original Triple Aim Framework (16) was developed by the Institute for Healthcare Improvement. It describes an approach to optimizing health system performance by simultaneously pursuing three aspects of quality: patient experience of care (including quality and satisfaction), health of populations, and reducing the per capita cost of providing healthcare. More recently several groups have advocated to add a fourth aim: healthcare worker experience in providing care.
Reckless behaviour (Ref 18)
Intentional risk-taking; a conscious decision to act without regard to a known, substantial and unjustifiable risk. Careful consideration of all the facts and circumstances of the situation is needed to determine if the decision to act was unjustifiable.
Reporting culture (Ref 17)
An organizational climate in which people are prepared to report their errors and close calls.
Responsible (Responsibility) (Ref 7)
Being in charge; being the owner of a task or action. Responsibility can be shared.
Risk (Ref 6)
The probability of being exposed to danger, or the probability of experiencing loss or injury.
Safety culture (Ref 13)
Organizations with a safety culture gather appropriate safety information, learn from it and use it to continually improve patients’ safety.
A safety culture requires a reporting culture. Effective reporting only happens within a just culture. An organization that is both ‘just’ and ‘reporting’ will be better able to use information to continually improve safety i.e., have a learning culture. Taken together, these three elements of culture – reporting, just, and learning – characterize an organization with a safety culture.
System (Ref 6)
In healthcare, a set of interdependent components interacting to achieve a common aim. The components can be classified in different ways depending on the situation e.g., patient, personnel (healthcare workers), equipment/environment, organization, regulatory agency.
System factors (Ref 8)
Characteristics that exist within the various components of the healthcare system* that may positively or negatively contribute to a patient’s outcome.
* Healthcare system components: Patient, personnel, equipment/environment, organization, regulatory agency