Missed care is a subset of the category known as “error of omission.” It refers to care that is delayed, partially completed, or not completed at all. Missed care can result in lower safety culture ratings, increases in adverse events such as pressure injuries, and higher rates of postoperative mortality.
Misdiagnosis in the context of patient safety is an erroneous or delayed diagnosis and has the potential to cause patient harm. The term is frequently used interchangeably with "diagnostic error". Misdiagnoses can potentially prevent or delay appropriate treatment or result in unnecessary or harmful treatment, which can lead to physical, psychological, or financial harm to patients. Misdiagnosis can be caused by cognitive biases in clinicians or underlying systems-level issues in health care.
Mindfulness reflects an organizational and/or team ability to motivate and enculturate abilities and opportunities to create awareness of the myriad of facets affecting detection of potential or emergent situations before they unfold to prevent escalation into failure and provide understanding to coordinate a response during an incident. This can be accomplished through initiatives that involve multidisciplinary work and develop teams and relationships. The concept aligns with the core components of high reliability as defined by Weick/Sutcliff.
A medication safety officer is a clinical practitioner in a leadership role that has expertise in safe medication management practices across all stages of medication delivery. His or her leadership and expertise optimize best practices and address medication adverse events in a systems-based approach.
The Medication Administration Record (MAR) is a legal and permanent documentation of a patient’s medications administered, typically by a nurse in an acute or sub-acute setting. Use of technology (such as bar-coded medication administration) and standardized procedures (such as two-person verification or application of the “rights” of medication administration are included in the medication administration process to improve patient safety.
Learning systems build functions, networks, and processes to use data, information, evidence, and knowledge to implement change and, ultimately, to sustain improvements. Learning systems focus both on internal improvement and information sharing, as well as external distribution of data and knowledge using technology to generate improvement in the larger environment in which the organization functions. Learning systems nurture a culture that enables information sharing and improved collective awareness across the spectrum of the healthcare system.
Lean principles include standardized work, value stream, workflow, reducing waste, and efficiency with a focus on the customer experience. Application of Lean principles to healthcare settings increases patient safety and ensures that the patient’s healthcare experience is effective and of high quality. Researchers have used Lean methodology to improve processes related to chemotherapy preparation, surgical instrument sterilization, and medication administration.
Inattentional blindness is a cognition concept exploring why individuals in an intense or complex situation can miss an important event or data point because competing attentional tasks divide their focus. Individuals experiencing inattentional blindness unknowingly orient themselves toward, and process information from, only one part of their environment, while excluding others which can contribute to task omissions and missed signals, such as incorrect medication administration.
Human factors are the strengths and constraints in the design of interactive systems and actions involving people, tools and technology, and work environments to ensure their safety, reliability, and effectiveness. Ergonomics is a related term, which is the study of the interplay between human factors, technologies, and work environments.
Related term: human factors engineering
Cox C, Fritz Z. BMJ. 2022;377:e066720.
Chicago, IL: Harpo Productions, Smithsonian Channel: May 2022.