Magnet Hospital Status
A designation by the Magnet Hospital Recognition Program administered by the American Nurses Credentialing Center. The program has its genesis in a 1983 study conducted by the American Academy of Nursing that sought to identify hospitals that retained nurses for longer than average periods of time. The study identified institutional characteristics correlated with high retention rates, an important finding in light of a major nursing shortage at the time. These findings provided the basis for the concept of magnet hospital and led 10 years later to the formal Magnet Program.

Without taking anything away from the particular hospitals that have achieved Magnet status, the program as a whole has its critics. In fact, at least one state nurses' association (Massachusetts) has taken an official position critiquing the program, charging that its perpetuation reflects the financial interests of its sponsoring organization and the participating hospitals more than the goals of improving health care quality or improving working conditions for nurses. Regardless of the particulars of the Magnet Recognition Program and the lack of persuasive evidence linking magnet status to quality, to many the term magnet hospital connotes a hospital that delivers superior patient care and, partly on this basis, attracts and retains high-quality nurses.

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Medical Emergency Team
See Primer. The concept of medical emergency teams (also known as rapid response teams) is that of a cardiac arrest team with more liberal calling criteria. Instead of just frank respiratory or cardiac arrest, medical emergency teams respond to a wide range of worrisome, acute changes in patients' clinical status, such as low blood pressure, difficulty breathing, or altered mental status. In addition to less stringent calling criteria, the concept of medical emergency teams de-emphasizes the traditional hierarchy in patient care in that anyone can initiate the call. Nurses, junior medical staff, or others involved in the care of patients can call for the assistance of the medical emergency team whenever they are worried about a patient's condition, without having to wait for more senior personnel to assess the patient and approve the decision to call for help.

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Medication Reconciliation
See Primer. Unintended inconsistencies in medication regimens occur with any transition in care. Medication reconciliation refers to the process of avoiding such inadvertent inconsistencies by reviewing the patient's current medication regimen and comparing it with the regimen being considered for the new setting of care.

Mental Models
Mental models are psychological representations of real, hypothetical, or imaginary situations. Scottish psychologist Kenneth Craik (1943) first proposed mental models as the basis for anticipating events and explaining events (i.e., for reasoning). Though easiest to conceptualize in terms of mental pictures of objects (e.g., a DNA double helix or the inside of an internal combustion engine), mental models can also include "scripts" or processes and other properties beyond images. Mental models create differing expectations, which suggest different courses of action. For instance, when you walk into a fast-food restaurant, you are invoking a different mental model than when in a fancy restaurant. Based on this model, you automatically go to place your order at the counter, rather than sitting at a booth and expecting a waiter to take your order.

Metacognition refers to thinking about thinking—that is, reflecting on the thought processes that led to a particular diagnosis or decision to consider whether biases or cognitive short cuts may have had a detrimental effect. Numerous cognitive biases affect human reasoning. In some ways, metacognition amounts to playing devil's advocate with oneself when it comes to working diagnoses and important therapeutic decisions. However, the devil is often in the details—one must become familiar with the variety of specific biases that commonly affect medical reasoning. For instance, when discharging a patient with atypical chest pain from the emergency department, you might step back and consider how much the discharge diagnosis of musculoskeletal pain reflects the sign out as a "soft rule out" given by a colleague on the night shift. Or, you might mull over the degree to which your reaction to and assessment of a particular patient stemmed from his having been labeled a "frequent flyer." Another cognitive bias is that clinicians tend to assign more importance to pieces of information that required personal effort to obtain.

In some contexts, errors are dichotomized as slips or mistakes, based on the cognitive psychology of task-oriented behavior. Mistakes reflect failures during attentional behaviors—behavior that requires conscious thought, analysis, and planning, as in active problem solving. Rather than lapses in concentration (as with slips), mistakes typically involve insufficient knowledge, failure to correctly interpret available information, or application of the wrong cognitive heuristic or rule. Thus, choosing the wrong diagnostic test or ordering a suboptimal medication for a given condition represents a mistake. Mistakes often reflect lack of experience or insufficient training. Reducing the likelihood of mistakes typically requires more training, supervision, or occasionally disciplinary action (in the case of negligence).

Unfortunately, health care has typically responded to all errors as if they were mistakes, with remedial education and/or added layers of supervision. In point of fact, most errors are actually slips, which are failures of schematic behavior that occur due to fatigue, stress, or emotional distractions, and are prevented through sharply different mechanisms.

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