Glossary

This glossary is not intended to be an exhaustive list of terms, but rather a concise list of key terms used throughout the toolkit. 

Actions (taken to reduce risk of harm): Actions taken to reduce, manage, or control any future harm, or probability of harm. 

Alerts or advisories: An alert or advisory is a piece of information that has been produced and publicly posted that outlines a specific type of patient safety incident or series of incidents that did occur or could occur.  

Apology: A genuine expression of sympathy or regret, a statement that one is sorry for what has happened. An apology includes an acknowledgement of responsibility if such responsibility has been determined after the analysis of the adverse event. 

Authority gradient:  Balance of decision-making power or the steepness of command and hierarchy in a given situation. 

Contributing factors: A circumstance, action or influence which is thought to have played a part in the origin or development of an incident or to increase the risk of an incident. 

Culture, Patient Safety: Culture refers to shared values (what is important) and beliefs (what is held to be true) that interact with a system’s structures and control mechanisms to produce behavioural norms. 

Disclosure: The process by which a patient safety incident is communicated to the patient by health care providers. 

Early warning system:  A systemic process for evaluating and measuring risks early in order to take pre-emptive steps to minimize their impact. 

Governance:  The body having accountability and legal responsibility for the overall performance of an organization and oversight of decisions. 

Harm: Impairment of structure or function of the body and/or any deleterious effect arising therefrom. Harm includes disease, injury, suffering, disability and death. 

Hazard: Situations with the potential to cause harm. 

Healthcare organization: An organization that provides health services in any healthcare sector. 

High Reliability Organizations (HROs):  Organisations that have few accidents despite operating in highly dynamic, technologically rich and hazardous industries. 

Human Factors: A discipline addressing human behaviour, abilities, limitations, and relationship to the work environment (physical, organizational, cultural), with the goal to promote efficiency, safety and effectiveness by improving the design of technologies, processes and work systems.. 

Incident Analysis:  A structured process that aims to identify what happened, how and why it happened, what can be done to reduce the risk of recurrence and make care safer, and what was learned.  It is also referred to as system-based analysis. 

Incident Management: The various actions and process required to conduct the immediate and ongoing activities following an incident.  Incident analysis is a component of incident management. 

Patient safety incident:  An event or circumstance which could have resulted, or did result, in unnecessary harm to a patient. There are three types of patient safety incidents: 

• Harmful incident: A patient safety incident that resulted in harm to the patient. Replaces "preventable adverse event” 
• Near miss: A patient safety incident that did not reach the patient and therefore no harm resulted. 
• No-harm incident: A patient safety incident that reached the patient but no discernible harm resulted. 

Patient safety: The pursuit of the reduction and mitigation of unsafe acts within the health care system, as well as the use of best practices shown to lead to optimal patient outcomes. 

Patient: A person who is receiving, has received, or has requested health care. 

Family: A person(s) whom the patient wishes to be involved with them in care, and acting on behalf of and in the interest of the patient.  

Prospective analysis:  An analytical tool to assess and mitigate harm or loss by analyzing a situation or process that carries with it some inherent risk. Its purpose is to identify the way in which a process might potentially fail, with the goal to eliminate or reduce the likelihood or outcome severity of such a failure.  

Providers: Refers to physicians, professional, unregulated staff, and others engaged in the delivery of health services. 

Quality Improvement (QI): A formal approach to the analysis of performance and systematic efforts to improve it. There are numerous models used. 

Reporting:  The communication of information about a patient safety incident through appropriate channels inside or outside of healthcare organizations, for the purpose of reducing the risk of occurrence of patient safety incidents in the future. 

Resilience: The degree to which a system continuously prevents, detects, mitigates or ameliorates hazards or incidents so that an organization can “bounce back” to its original ability to provide core functions. 

Risk management:  An organized effort to identify, assess and reduce, where appropriate, risks to patients, visitors, staff and organizational assets. Activities are undertaken to identify, analyze and educate, and to structure processes to reduce the likelihood of adverse events. 

Risk mitigation: The process of identifying and implementing precautions or controls that will most effectively reduce the consequence or likelihood of occurrence of a risk. 

Risk: The probability that a specific adverse event will occur in a specific time period or as a result of a specific situation. 

System Levels:  Systems are generally viewed from various levels because they are differences in goals, structures and ways of working in different parts of the system.  

System:  A health system, or healthcare system, is the sum of all the organizations, institutions, and resources whose primary purpose is to deliver health care services to meet the health needs of a target population. 

Systems Thinking:  An approach that centers on the dynamic interaction, synchronization and integration of system components and sub-components (e.g. people, processes, technology, incentives, decisions, culture). 

Team:  Two or more people who interact dynamically, interdependently, and adaptively toward a common and valued goal/objective/ mission. Patients/families are part of the team.  

Teamwork:  Team members working together to achieve a shared goal. 

Note to Quebec Readers: 

The toolkit was developed by and for English and French speaking Canadians and the terms used throughout were chosen by consensus. However, given the provisions contained in the Act Respecting Health Services and Social Services (R.S.Q., chapter S-4.2) effective in Quebec, various terms have been  adapted. During the toolkit development we also consulted with Accreditation Canada to maintain consistency with the revised Disclosure and Incident Management Required Organizational Practices (2014) and the patient safety terminology used therein. Please make the necessary conversions when reading this toolkit text.