National Academies Press: OpenBook

To Err Is Human: Building a Safer Health System (2000)

Chapter: B Glossary and Acronyms

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Suggested Citation:"B Glossary and Acronyms." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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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.

Suggested Citation:"B Glossary and Acronyms." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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Page 211

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, descriptions, explanations, abbreviations, or acronyms.

5. Standard guide—a series of options or instructions that do not recommend a specific course of action.

6. Standard classification—a systematic arrangement or division of products, 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.).

Suggested Citation:"B Glossary and Acronyms." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×

Page 212

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

Suggested Citation:"B Glossary and Acronyms." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×

Page 213

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.

Suggested Citation:"B Glossary and Acronyms." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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Suggested Citation:"B Glossary and Acronyms." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 210
Suggested Citation:"B Glossary and Acronyms." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 211
Suggested Citation:"B Glossary and Acronyms." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 212
Suggested Citation:"B Glossary and Acronyms." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 213
Suggested Citation:"B Glossary and Acronyms." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 214
Next: C Literature Summary »
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Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDS--three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems.

To Err Is Human breaks the silence that has surrounded medical errors and their consequence--but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agenda--with state and local implications--for reducing medical errors and improving patient safety through the design of a safer health system.

This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes.

Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errors--which begs the question, "How can we learn from our mistakes?"

Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care.

To Err Is Human asserts that the problem is not bad people in health care--it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocates--as well as patients themselves.

First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine

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