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Underdiagnosis involves delayed or missed diagnosis of a medical condition. It may occur through either acts of omission (e.g., overuse of inappropriate tests) or commission (e.g., underuse of appropriate tests). There may be healthcare disparities associated with underdiagnosis such missed diagnosis of acute myocardial infarction in women or missed diagnosis of depression in African American patients.
Triggers are a type of clue that can be used to identify an adverse event (AE) or error. A simple example is identifying that the drug Naloxone was administered to determine whether there was an opioid overdose, which is an adverse event, if occurring in a clinical setting. Trigger tools are instruments that have been designed to identify adverse events so organizations are able to measure and track the events. Trigger tools allow healthcare organizations to identify greater numbers of AEs than happens with voluntary reporting. IHI has a Global Trigger Tool that has many different types of triggers for adverse events.
Transition of care reflect the period of time when patients move between one health care unit to another that are in different locations and offer different levels of care
Transparency in healthcare emphasizes providing information on healthcare quality, safety, and consumer experience with care in a reliable and understandable manner. Transparency is aimed at promoting patient safety by building trust between patients, providers, the organization, and society at large, with the goal of improved safety, informed communication, and increased knowledge. Transparency can occur at the individual level (i.e., disclosure of medical errors by clinicians to patients and families) as well as organizational levels (such as public reporting activities from CMS, AHRQ, and Leapfrog).
Teams are groups of individuals who work dynamically, interdependently, and collaboratively towards a common goal, while retaining specific individual roles or functions. Team members should (1) include anyone involved in the patient care process (including leaders), (2) have clearly defined roles and responsibilities, (3) be accountable to the team for their actions and (4) stay continually informed for effective team functioning. It is important that teams are representative not only of different professions but reflect diversity in the team members (sex, age, race, ethnicity, culture, etc.) so that the team is representative of the population they serve. AHRQ has developed an evidence-based program called TeamSTEPPS® that provides tools for healthcare teams in different types of organizations, particularly focusing on improved communication.
Stewardship refers to efforts by healthcare providers (e.g., clinicians, hospitals, doctor’s offices, pharmacies, etc.) to promote the safe and appropriate use of healthcare resources. Recent stewardship priorities have focused on appropriate use of opioids and antimicrobials. The concept of “stewardship” was first introduced by the World Health Organization (WHO) to clarify the practical components of governance in the health sector; their focus was on how governments take responsibility for the health system and the wellbeing of the population, fulfill health system functions, assure equity, and coordinate interaction with government and society.
The term “second victim” refers to health care workers who are involved in medical errors and adverse events and experience emotional distress. Some patient safety researchers and advocates have raised concerns regarding the use of the term, and others suggest that its appropriateness depends on hospital culture and context.
SBAR (Situation, Background, Assessment, Recommendation) is a concise, standardized process to clearly communicate information between individuals or groups. The Situation names the safety issue, Background provides known evidence and context, Assessment states the impression for next steps, and the Recommendation includes the plan to improve or remedy the patient safety issue. SBARs have commonly been used to support situational awareness and improve handoff communications. SBARs are also used to analyze patient safety events and develop potential solutions to communicate with other stakeholders, such as hospital leadership.
Safety I/II reflect two perspectives to understanding safety improvements. The Safety I approach focuses on identifying causes and contributing factors to adverse events without considering human performance. The Safety II approach considers variations in everyday performance to understand how things usually go right. Under the Safety-I framework, procedural violations in the health care setting might be viewed unfavorably. In the Safety-II framework, procedural violations may be seen as necessary modifications within a complex work environment. The application of both frameworks provides deeper understanding of procedural violations and facilitates the development of targeted interventions for improving safety.
Resilience engineering is the organizational capability to design processes and actions to systemically track data, information, evidence, and knowledge to anticipate and respond to challenges, as well as to correct disrupted processes back to standardized, improved states based on the application of lessons learned during the disruption. Processes are then hardwired to incorporate those changes and support continuous adjustment to sustain said improvements–in essence to learn from disruptions–to prevent future problems and failure and become resilient.
Related term: Resilience
Resilience is a characteristic that enables organizations to adapt to uncertain conditions in their work environment. Resilient organizations are able to anticipate risk and continuously adapt to the complexity of their work environments to prevent failure. While important, personal resilience is not the focus of this definition, but resilience as an organizational trait helps to minimize the overreliance on individual resilience through strengthening the organizational capacity to minimize disruption.
Related term: Resilience Engineering
Psychological safety is the belief that speaking up will not result in negative consequences for oneself, such as punishment or humiliation. Psychological safety within health care teams fosters patient safety by allowing team members to feel accepted, respected, and able to share their ideas, questions, concerns and mistakes.
Preventability in the context of patient safety is the extent to which a patient safety adverse event or harm is preventable. Preventable adverse events occur because of an error or failure to apply strategies for error prevention. One in 10 patients are harmed while receiving inpatient care in hospitals and four in 10 patients are harmed in primary and outpatient care. This harm is caused by a range of adverse events, and 50%-80% of these events are preventable. In terms of prevalence, preventable patient safety events are most frequently related to diagnosis, prescription, or medication delivery processes.
Patient Safety Organizations (PSOs) were established through the Patient Safety and Quality Improvement Act that authorized the Department of Health and Human Services (HHS) to establish a voluntary system of reporting and analyzing data to evaluate and improve patient safety. PSOs work with healthcare providers (e.g., hospitals, nursing homes, dialysis centers) to assist them with their patient safety programs by analyzing the data submitted and providing feedback on ways to improve patient safety. AHRQ is the agency responsible for the oversight of the PSO program.
Patient Safety Officers are individuals assigned to lead patient safety efforts in health care organizations, and who are responsible for the management of the patient safety program. They are accountable for assessing the organization’s patient safety measures, ensuring staff are trained, promoting actions to identify and respond to patient safety events, and ensuring that senior leadership is knowledgeable about the status of the patient safety events and overall status of the program.
Overdiagnosis involves identifying medical issues in people that were not going to be medically significant or cause harm. It may occur due to unnecessary screening of asymptomatic people, unneeded investigations in individuals with symptoms, or inappropriate reliance on laboratory or radiographic studies. Overdiagnosis can cause more harm than benefit. It can lead to unnecessary testing and treatment that ultimately adversely affects patient safety and well-being.
Organizational learning is an environmental state that ensures lessons from lived experience within a work environment are fed into, and embedded within, the organization’s policies and culture to ensure perpetual improvement. Activities supporting organizational learning include detection and reporting and discussion of safety issues by frontline staff, and promotion of experimentation and creative problem-solving in order to minimize the stigma of failures.
In healthcare, moral distress or moral injury occurs when a person knows the ethically appropriate action to take but is constrained from taking that action. The constraints can come from multiple external factors, but they can also come from institutional or organizational regulations that do not align with the person’s moral principles, or when the person feels powerless to act on their moral beliefs.