Glossary and Acronym List
An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient.
Adverse event triggers.
Clinical data related to patient care indicating a reasonable probability that an adverse event has occurred or is occurring. An example of trigger data for an adverse drug event is a physician order for an antidote, a medication stop, or a dose decrease.
A computer-generated output that is created when a record meets prespecified criteria; for example, receipt of a new laboratory test result with an abnormal value (Shortliffe et al., 2001).
Primitive knowledge that cannot be defined from other knowledge.
A process for positive and unique identification of users, implemented to control system access (Shortliffe et al., 2001).
A decision support system that uses a database of similar cases (van Bemmel, 1997).
Causal continuum assumption.
The assumption that the (failure) causal factors of consequential accidents are similar to those of nonconsequential near misses.
The retrospective review of the patient’s complete written record by an expert for the purpose of a specific analysis. For patient safety, to identify possible adverse events by reviewing the physician and nursing progress notes and careful examination for certain indicators.
A taxonomy that arranges or organizes like or related terms for easy retrieval (National Committee on Vital and Health Statistics, 2000).
Clinical data repository.
Clinical database optimized for storage and retrieval for information on individual patients and used to support patient care and daily operations (Shortliffe et al., 2001).
Clinical Document Architecture.
A document markup standard that specifies the structure and semantics of “clinical documents” for the purpose of exchange (Van Hentenryck, 2001).
A clinical area of interest that might be modeled for a clinical information system. (van Bemmel, 1997)
Clinical event monitor.
Rule-based programs that sit atop a clinical data repository, supporting real-time error prevention.
Clinical information systems.
The components of a health care information system designed to support the delivery of patient care, including order communications, results reporting, care planning, and clinical documentation (Shortliffe et al., 2001).
An event or situation that could have resulted in an adverse event but did not, either by chance or through timely intervention (U.S. Department of Veterans Affairs, 2002).
A numeric or alphanumeric representation assigned to a term so that it may be more readily processed (National Committee on Vital and Health Statistics, 2000).
Ability to compare similar data held in different computer systems. Comparability requires that the meaning of data is consistent when shared among different parties (National Committee on Vital and Health Statistics, 2000).
Computer detection rules.
Boolean combinations of medical events, for example, new medication orders and laboratory results outside certain limits that suggest an adverse drug event might be present.
Computerized physician order entry (CPOE).
Clinical systems that utilize data from pharmacy, laboratory, radiology, and patient monitoring systems to relay the physician’s or nurse practitioner’s diagnostic and therapeutic plans and alert the provider to any allergy or contraindication that the patient may have so that the order may be immediately revised
at the point of entry prior to being forwarded electronically for the targeted medical action (First Consulting Group, 2003).
Elements of the terminology are coded concepts, with possibly multiple synonymous text representations and hierarchical or definitional relationships to other coded concepts. No redundant, ambiguous, or vague concepts exist (Sujansky, 2003).
The meaning of each coded concept in a terminology remains forever unchanged. If the meaning of a concept needs to be changed or refined, a new coded concept is introduced. No retired codes are deleted or reused (Sujansky, 2003).
A model of the main concepts of a domain and their relationships (van Bemmel, 1997).
Consistency of views.
Consistency of views says that concepts in multiple classes have the same appearance in each context (e.g., corticosteroid as hormone or antiinflammatory agent has the same attributes and descendant concepts).
The input of data into a computer system through direct data entry, collection from a medical device, or other means (Shortliffe et al., 2001).
The basic unit of information having a unique meaning and subcategories of distinct units or values (van Bemmel, 1997).
Data interchange standards.
Syntactic and semantic rules for defining data elements and which govern the seamless communication between computer systems while preserving the meaning of the data and intended functions.
The use of a basic set of tools to extract patterns from the data in a data warehouse (van Bemmel, 1997).
A group of data elements specifically selected for a particular clinical purpose, such as clinical quality measurement, patient safety reporting, etc.
Defines how a data element is formatted or expressed. Simple data types include date, time, numeric, string, blob (large binary objects, such as images), currency, or coded element; complex data types include a structure for names, addresses, etc. (Hammond, 2002).
Database optimized for long-term storage, retrieval, and analysis of records aggregated across patient populations, often serving the longer term business and clinical analysis needs of an organization. (Shortliffe et al., 2001).
Decision support systems.
A system consisting of a knowledge base and an inference engine that is able to use entered data to generate advice (van Bemmel, 1997).
A diagrammatic representation of the outcomes associated with chance events and voluntary actions (Shortliffe et al., 2001).
Drawing of plausible inferences on the basis of less than conclusive evidence in the absence of information to the contrary.
Knowledge that can be defined or constructed from other knowledge.
Domain completeness must not restrict terminology size through presuppositions about ultimate dimensions (e.g., no preset coding system that restricts depth or breadth of the hierarchy).
Electronic health record.
A repository of electronically maintained information about an individual’s health care and corresponding clinical information management tools that provide alerts and reminders, linkages with external health knowledge sources, and tools for data analysis (Shortliffe et al., 2001).
The process of encoding (scrambling) data such that a specific key is needed to decode the data. Most methods are based on the use of prime numbers (van Bemmel, 1997).
The failure of a planned action to be completed as intended (i.e., error of execution), and the use of a wrong plan to achieve an aim (i.e., error of planning) (Institute of Medicine, 2000). It also includes failure of an unplanned action that should have been completed (omission).
Scientific evidence is a replicable and generalizable observation that can be experienced nearly identically by independent people from different places and at different times.
Consensus approaches for handling recurring health management problems aimed at reducing practice variability and improving health outcomes. Guideline development emphasizes using clear evidence from the existing literature, rather than expert opinion alone, as the basis for advisory materials (Shortliffe et al., 2001).
The relationships between concepts in a hierarchy are clearly defined (e.g., relationship between staphylococcal pneumonia and pneumonia is differentiated from relationship between staphylococcal pneumonia and staphylococcus, where the former is a class relation and the latter is an etiologic relation).
Extensible markup language (XML).
A specification designed specifically
for Web documents. It allows designers to create their own customized tags to provide functionality not available with HTML (Newton, 2001).
Health care terminology.
A collective term used to describe the continuum of code set, classification, and nomenclature (vocabulary) (National Committee on Vital and Health Statistics, 2000).
Injury originating from or caused by a physician (iatros, Greek for “physician”), including unintended or unnecessary harm or suffering arising from any aspect of health care management, including problems arising from acts of commission or omission.
The science that studies the use and processing of data, information, and knowledge (van Bemmel, 1997).
The ability of one computer system to exchange data with another computer system such that, at a minimum, the message from the sending system can be placed in the appropriate place in the receiving system (National Committee on Vital and Health Statistics, 2000).
A component of production rule system deciding which rule to execute on each selection execute cycle.
A discriminating or authoritative appraisal, opinion, or decision, based on sound and reasonable evaluation.
A collection of systematically stored facts, heuristics, and models that can be used to make decisions or solve problems (Shortliffe et al., 2001).
Expresses medical knowledge in computer-tractable form.
Knowledge representation formalism.
Formalism used to express knowledge. Also known as knowledge representation language.
Knowledge representation language.
Formalism used to express knowledge. Also known as knowledge representation formalism.
Levels of evidence.
It is widely recognized that various scientific methodologies produce various levels of evidence, that is, chances of identical experience when replicated by independent observers. In the testing of presumably beneficial health care interventions, the multicenter randomized controlled clinical trial is widely regarded as the top-quality source due to the demonstrable weaknesses of alternative methodolo-
gies. Randomized trials are central to Food and Drug Administration drug approval, strongly preferred information sources by most clinical practice guidelines, and prominently featured by the international Cochrane collaboration. When randomization is not possible or randomized controlled trial results are not available, original research data from controlled observations represent the next best choice (e.g., linking risky behaviors to adverse effects).
Components of semantic nets representing relationships between objects.
Those patient safety reporting systems that by legislation and/or regulation require the reporting of specified adverse events, generally events of serious harm and death.
The process of cross-linking terms from different terminologies so that comparisons and analyses can be undertaken.
Multiple classification must not restrict terminology such that a concept is prevented from being assigned to as many classes as required (e.g., “viral pneumonia” can be in classes “pneumonia” and “viral diseases”).
National Health Information Infrastructure (NHII).
A set of technologies, standards, applications, systems, values, and laws that support all facets of individual health, health care, and public health (National Committee on Vital and Health Statistics, 2001).
Natural language processing (NLP).
Accessing data in the narrative form or free text and creating machine-understandable interpretations of those data (van Bemmel, 1997).
An error of commission or omission that could have harmed the patient, but serious harm did not occur as a result of chance (e.g., the patient received a contraindicated drug but did not experience an adverse drug reaction), prevention (e.g., a potentially lethal overdose was prescribed, but a nurse identified the error before administering the medication), or mitigation (e.g., a lethal drug overdose was administered but discovered early and countered with an antidote).
A system in hardware or software of interconnected nodes developed in analogy with the human brain (van Bemmel, 1997).
Components of semantic nets representing objects or classes of objects.
A nomenclature, or vocabulary, is a set of specialized terms
that facilitate precise communication by eliminating ambiguity (National Committee on Vital and Health Statistics, 2000).
Nonambiguity says that concepts must have exactly one meaning and, where a common term has two or more associated meanings (homonymy), they must be disambiguated into distinct concepts (e.g., “Paget disease” must be split into “Paget disease of the bone” and “Paget disease of the breast”) (Cimino, 1998).
Nonredundancy says that a mechanism must exist that can help prevent multiple terms for the same concept from being added to the terminology as unique concepts.
Nonvagueness says that concepts in the terminology must be complete in meaning (e.g., “ventricle” is not usually considered a fully described concept, nor does it represent some generic class of anatomic terms, i.e., it means neither “heart ventricle” nor “brain ventricle” when taken out of context).
Notational aspect of knowledge representation language.
The way in which information is stored in an explicit format. Also known as syntactic aspect of knowledge representation language.
The prevention of harm caused by errors of commission and omission.
Knowledge of how other than that.
A component of logic system that is a formal specification of the notion of correct inference.
An informal set of human factors that lead to a risky situation being detected, understood, and corrected in time, thus limiting the sequence to a near-miss outcome, instead of it developing further into possibly an adverse event.
Concept-oriented terminologies possessing characteristics such as a grammar that defines the rules for automated generation and classification of new concepts as well as combination of atomic concepts to form molecular expressions (Spackman et al., 1997).
Sets of data elements required for reporting purposes.
A process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event. Typically, the analysis focuses primarily on systems and processes, not individual performance (Joint Commission on Accreditation of Healthcare Organziations, 2003).
A component of production rule system that represents knowledge as “if-then” rules.
Safe care involves making evidence-based clinical decisions to maximize the health outcomes of an individual and to minimize the potential for harm. Both errors of commission and omission should be avoided.
Defined by the National Research Council as an event that, under slightly different circumstances, could have been an accident.
Components of logic system that specify the meanings of the well-formed expressions of the logical language.
Components of the frame system that describe objects.
A property of logic system that every sentence derived from a set of sentences is also a valid consequence of that set of sentences.
A set of characteristics or quantities that describes features of a product, process, service, interface, or material. The description can take many forms, such as the definition of terms, specification of design and construction, detailing of procedures, or performance criteria against which a product, process, and other factors can be measured (National Research Council, 1995).
Routine collection and review of data to examine the extent of a disease, to follow trends, and to detect changes in disease occurrence, such as infectious disease surveillance, postmarketing surveillance, etc. (van Bemmel, 1997).
Synonomy supports multiple nonunique names for concepts.
Syntactic aspect of knowledge representation language.
The way in which information is stored in an explicit format. Also known as notational aspect of knowledge representation language.
The rules (grammar) for the description, storage, and transmission of messages or for the composition of a program statement (van Bemmel, 1997). The rules that specify the legal symbols and constructs of a language (Shortliffe et al., 2001).
Terminologies define, classify, and in some cases code data content.
A conceptual layer of a system architecture that insulates the programs designed to interact with users from the underlying data and the applications that process those data (Shortliffe et al., 2001).
Those reporting systems for which the reporting of patient safety events is voluntary (not mandatory). Generally, reports on all types of events are accepted.
A component of production rule system containing information that the system has gained about the problem thus far.
adverse drug event
Adverse Event Reporting System
Agency for Healthcare Research and Quality
Australian Incident Monitoring System
acute myocardial infarction
American National Standards Institute
Accredited Standards Committee
Alternative Summary Reporting—Medical Devices
American Society for Testing and Materials
Blood Product Deviation Reporting System
Clinical Document Architecture
Centers for Disease Control and Prevention
Comité Européean Normalisation
congestive heart failure
Consolidated Health Informatics
Children’s Health Insurance Program
clinical information systems
Centers for Medicare and Medicaid Services
chronic obstructive pulmonary disease
Risk Assessment of Security Critical Systems
computerized physician order entry
Current Procedural Terminology
continuous quality improvement
Center for Quality Improvement and Patient Safety
Department of Health and Human Services
Digital Imaging and Communications in Medicine
Department of Defense
Diabetes Quality Improvement Project
Diagnostic and Statistical Manual
Dialysis Surveillance Network
External Causes and Injury Codes
Evidence-based Practice Center
end-stage renal disease
Foundation for Accountability
First Consulting Group
Food and Drug Administration
failure mode and effect analysis
Guideline Expression Language, Object Oriented
Guideline Interchange Format
Generic Reference Model
hazard analysis and critical control points
hazard and operability studies
Health Care Financing Administration
Health Care Financing Administration Common Procedure Coding System
Healthcare failure mode and effect analysis
Home Health Care Classification
Healthcare Information Management Systems Society
Health Insurance Portability and Accountability Act of 1996
Health Level Seven
International Classification of Diseases, Ninth Edition, Clinical Modification
International Classification of Diseases, Tenth Edition
International Classification of Diseases, Oncology
International Classification of Functioning, Disability and Health
International Classification of Nursing Practice
International Classification of Primary Care
Institute of Electrical and Electronics Engineers
Integrating the Healthcare Enterprise
Institute of Medicine
Institute for Safe Medication Practice
International Organization for Standardization
Journal of American Informatics Association
Joint Commission on Accreditation of Healthcare Organizations
Logical Observation Identifiers, Names and Codes
Manufacture and User Data Experience-Medical Devices
Minimum Data Set for Nursing Home Care
Medical Dictionary for Drug Regulatory Affairs
Medical Product Surveillance Network
Medication Errors Reporting
Medical Event Reporting System for Transfusion Medicine
Medical Subject Headings
Military Health System Patient Safety Program
Medicare Patient Safety Monitoring System
magnetic resonance imaging
North American Nursing Diagnosis Association
National Aeronautics and Space Administration
National Surveillance System for Health Care Workers
National Academy for State Health Policy
National Center for Health Statistics
National Council for Prescription Drug Programs
National Center for Patient Safety
National Committee for Quality Assurance
National Committee on Vital and Health Statistics
National Drug Code
National Drug File Clinical Drug Reference Terminology
National Electronic Disease Surveillance System
National Equipment Manufacturers Association
national health information infrastructure
National Healthcare Safety Network
Nursing Intervention Classification
National Library of Medicine
natural language processing
National Nosocomial Infections Surveillance
Nursing Outcomes Classifications
National Patient Safety Foundation
negative predictive value
National Quality Forum
National Research Council
New York Patient Occurrence Reporting and Tracking System
Outcome and Assessment Information Set for Home Care
Program for Appropriate Technology in Health
Patient Care Data Set
primary care physician
proactive hazard analysis
patient medical record information
Perioperative Nursing Data Set
positive predictive value
prevention quality indicator
probabilistic risk assessment
patient safety data standards
patient safety reporting system
quality indicators for patient safety
Quality Interagency Coordination Task Force
Reference Information Model
Radiological Society of North America
normalized notations for clinical drugs
Safety Assessment Code
Special Nutritionals Adverse Event Monitoring System
Systemized Nomenclature for Human and Veterinary Medicine, Clinical Terms
Statewide Planning and Research Cooperative System
Toyota Production System
total quality management
University of California, San Francisco
universal health identifier
Universal Medical Device Nomenclature System
Unified Medical Language System
United States Pharmacopeial Convention, Inc.
Vaccine Adverse Event Reporting System
Veterans Health Administration
Vaccine Safety Datalink
World Organization of National Colleges, Academies, and Academic Associations of General Practitioners and Family Physicians
extensible markup language
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