The Joint Commission Annual Report Shows Further Improvement in Health Care Quality in Nation's Hospitals
http://www.jointcommission.org
我們要評定領導者，除了考慮其不犯error of commission（因有所作為而犯錯，即做了不該做的，例如把共同因當特殊因處理等
Error of Commission
An error which occurs as a result of an action taken. Examples include when a drug is administered at the wrong time, in the wrong dosage, or using the wrong route; surgeries performed on the wrong side of the body; and transfusion errors involving blood cross-matched for another patient.
提供藥品服務(給病人用藥)的時間錯誤 或錯劑量 或路徑錯誤
開刀錯身體另一邊 輸錯交叉配血型之錯
能動失效
Active Failure
An error which is precipitated by the commission of errors and violations. These are difficult to anticipate and have an immediate adverse impact on safety by breaching, bypassing, or disabling existing defenses.
違反 回避 或使既有的防衛, 防御（物）而造成立即的安全問題作用
Error of Omission
An error which occurs as a result of an action not taken, for example, when a delay in performing an indicated cesarean section results in a fetal death, when a nurse omits a dose of a medication that should be administered, or when a patient suicide is associated with a lapse in carrying out frequent patient checks in a psychiatric unit. Errors of omission may or may not lead to adverse outcomes. 顯示應剖腹生產可是因遲疑而造成胎死腹中
護士在該給病人服藥時卻忘掉了ㄅ或是在精神病院中因疏忽未能經常查
| Sentinel Event Glossary of Terms |
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Accreditation Watch
An attribute of an organization's Joint Commission accreditation status. A health care organization is placed on Accreditation Watch when a reviewable sentinel event has occurred and has come to the Joint Commission's attention, and a thorough and credible root cause analysis of the sentinel event and action plan have not been completed within a specified time frame.
Action Plan
The product of the root cause analysis which identifies the strategies that an organization intends to implement to reduce the risk of similar events occurring in the future. The plan should address responsibility for implementation, oversight, pilot testing as appropriate, time lines, and strategies for measuring the effectiveness of the actions.
Active Failure
An error which is precipitated by the commission of errors and violations. These are difficult to anticipate and have an immediate adverse impact on safety by breaching, bypassing, or disabling existing defenses.
Adverse Drug Event (adverse drug error)
Any incident in which the use of a medication (drug or biologic) at any dose, a medical device, or a special nutritional product (for example, dietary supplement, infant formula, medical food) may have resulted in an adverse outcome in a patient.
Adverse Drug Reaction (ADR)
An undesirable response associated with use of a drug that either compromises therapeutic efficacy, enhances toxicity, or both.
Adverse Event
An untoward, undesirable, and usually unanticipated event, such as death of a patient, an employee, or a visitor in a health care organization. Incidents such as patient falls or improper administration of medications are also considered adverse events even if there is no permanent effect on the patient.
Aggregate Data
Data collected and reported by organizations as a sum or total over a given time period, for example, monthly or quarterly.
Barrier Analysis
The study of the safeguards that can prevent or mitigate (or could have prevented or mitigated) an unwanted event or occurrence. It offers a structured way to visualize the events related to system failure or the creation of a problem.
Benchmarking
Continuous measurement of a process, product, or service compared to those of the toughest competitor, to those considered industry leaders, or to similar activities in the organization in order to find and implement ways to improve it. This is one of the foundations of both total quality management and continuous quality improvement. Internal benchmarking occurs when similar processes within the same organization are compared. Competitive benchmarking occurs when an organization's processes are compared with best practices within the industry. Functional benchmarking refers to benchmarking a similar function or process, such as scheduling, in another industry.
Causation
The act by which an effect is produced. In epidemiology, the doctrine of causation is used to relate certain factors (predisposing, enabling, precipitating, or reinforcing factors) to disease occurrence. The doctrine of causation is also important in the fields of negligence and criminal law. Synonym: causality.
Change Analysis
A study of the differences between the expected and actual performance of a process. Change analysis involves determining the root cause of an event by examining the effects of change and identifying causes.
Circadian Rhythm
The rhythmic repetition of certain phenomena in living organisms at about the same time each day. Without cues provided by light, the human circadian cycle lasts 25.9 hours.
Clinical Pathway
A treatment regime, agreed upon by consensus, that includes all the elements of care, regardless of the effect on patient outcomes. It is a broader look at care and may include tests and x-rays that do not affect patient recovery. Synonym: clinical path.
Common-Cause Variation
See variation.
Complication
A detrimental patient condition that arises during the process of providing health care, regardless of the setting in which the care is provided. For instance, perforation, hemorrhage, bacteremia, and adverse reactions to medication (particularly in the elderly) are four complications of colonoscopy and its associated anesthesia and sedation. A complication may prolong an inpatient's length of stay or lead to other undesirable outcomes.
Coupled System
A system which links two or more activities so that one process is dependent on another for completion. A system can be loosely or tightly coupled.
Error of Commission
An error which occurs as a result of an action taken. Examples include when a drug is administered at the wrong time, in the wrong dosage, or using the wrong route; surgeries performed on the wrong side of the body; and transfusion errors involving blood cross-matched for another patient.
Error of Omission
An error which occurs as a result of an action not taken, for example, when a delay in performing an indicated cesarean section results in a fetal death, when a nurse omits a dose of a medication that should be administered, or when a patient suicide is associated with a lapse in carrying out frequent patient checks in a psychiatric unit. Errors of omission may or may not lead to adverse outcomes.
Fault Tree Analysis
A systematic way of prospectively examining a design for possible ways in which failure can occur. The analysis considers the possible direct proximate causes that could lead to the event and seeks their origins. Once this is accomplished, ways to avoid these origins and causes must be identified.
Flow Chart
A pictorial summary that shows with symbols and words the steps, sequence, and relationship of the various operations involved in the performance of a function or a process. Synonym: flow diagram.
FMECA (failure mode, effect, and criticality analysis)
A systematic way of examining a design prospectively for possible ways in which failure can occur. It assumes that no matter how knowledgeable or careful people are, errors will occur in some situations and may even be likely to occur.
Iatrogenic 1
Resulting from the professional activities of physicians, or, more broadly, from the activities of health professionals. Originally applied to disorders induced in the patient by autosuggestion based on a physician's examination, manner, or discussion, the term is currently applied to any undesirable condition in a patient occurring as the result of treatment by a physician (or other health professional), especially to infections acquired by the patient during the course of treatment. 2. Pertaining to an illness or injury resulting from a procedure, therapy, or other element of care.
Immediate Cause
See proximate cause.
Incident Report
The documentation for any unusual problem, incident, or other situation that is likely to lead to undesirable effects or that varies from established policies and procedures or practices. Synonym: occurrence report.
Indicator 1
A measure used to determine, over time, performance of functions, processes, and outcomes. 2. A statistical value that provides an indication of the condition or direction over time of performance of a defined process or achievement of a defined outcome.
Latent Failure
An error which is precipitated by a consequence of management and organizational processes and poses the greatest danger to complex systems. Latent failures cannot be foreseen but, if detected, they can be corrected before they contribute to mishaps.
Local Trigger
An intrinsic defect or atypical condition that can create failures.
Malpractice
Improper or unethical conduct or unreasonable lack of skill by a holder of a professional or official position; often applied to physicians, dentists, lawyers, and public officers to denote negligent or unskillful performance of duties when professional skills are obligatory. Malpractice is a cause of action for which damages are allowed.
Negligence
Failure to use such care as a reasonably prudent and careful person would use under similar circumstances.
Observation Method
An active method of error surveillance in which a trained observer watches the care delivery process.
Occurrence Screening
A system for concurrent or retrospective identification of adverse patient occurrences (APOs) through medical chart-based review according to objective screening criteria. Examples of criteria include admission for adverse results of outpatient management, readmission for complications, incomplete management of problems on previous hospitalization, or unplanned removal, injury, or repair of an organ or structure during surgery. Criteria are used organizationwide or adapted for departmental or topic-specific screening. Occurrence screening identifies about 80% to 85% of APOs. It will miss APOs that are not identifiable from the medical record.
Outcome
The result of the performance (or nonperformance) of a function(s) or process(es).
Pareto Chart
A special form of vertical bar graph that displays information in such a way that priorities for process improvement can be established. It shows the relative importance of all the data and is used to direct efforts to the largest improvement opportunity by highlighting the "vital few" in contrast to the "many others."
Plan-Do-Study-Act (PDSA) Cycle
A four-part method for discovering and correcting assignable causes to improve the quality of processes. Synonyms: Deming cycle; Shewhart cycle.
Process
A goal-directed, interrelated series of actions, events, mechanisms, or steps.
Proximate Cause
An act or omission that naturally and directly produces a consequence. It is the superficial or obvious cause for an occurrence. Treating only the "symptoms," or the proximate special cause, may lead to some short-term improvements, but will not prevent the variation from recurring.
Retrospective Review
1. A method of determining medical necessity or appropriate billing practice for services that have already been rendered. 2. In behavioral health, evaluative activities conducted when an individual being served is no longer in active treatment.
Risk Containment
Immediate actions taken to safeguard patients from a repetition of an unwanted occurrence. Actions may involve removing and sequestering drug stocks from pharmacy shelves and checking or replacing oxygen supplies or specific medical devices.
Risk Management
Clinical and administrative activities undertaken to identify, evaluate, and reduce the risk of injury to patients, staff, and visitors and the risk of loss to the organization itself.
Risk Points
Specific points in a process that are susceptible to error or system breakdown. They generally result from a flaw in the initial process design, a high degree of dependence on communication, non-standardized processes, and failure or absence of backup.
Root Cause
The most fundamental reason for the failure or inefficiency of a process.
Root Cause Analysis
A process for identifying the basic or causal factor(s) that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event.
Sentinel Event
An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called "sentinel" because they signal the need for immediate investigation and response.
Special-Cause Variation
See variation.
Surveillance
Ongoing monitoring using methods distinguished by their practicability, uniformity, and rapidity, rather than by complete accuracy. The purpose of surveillance is to detect changes in trend or distribution to initiate investigative or control measures. Active surveillance is systematic and involves review of each case within a defined time frame. Passive surveillance is not systematic. Cases may be reported through written incident reports, verbal accounts, electronic transmission, or telephone hotlines, for example.
Underlying Cause
The systems or process cause that allow for the proximate cause of an event to occur. Underlying causes may involve special-cause variation, common-cause variation, or both.
Variation
The differences in results obtained in measuring the same phenomenon more than once. The sources of variation in a process over time can be grouped into two major classes: common causes and special causes. Excessive variation frequently leads to waste and loss, such as the occurrence of undesirable patient health outcomes and increased cost of health services. Common-cause variation, also called endogenous cause variation or systemic cause variation, in a process is due to the process itself and is produced by interactions of variables of that process is inherent in all processes, not a disturbance in the process. It can be removed only by making basic changes in the process. Special-cause variation, also called exogenous-cause variation or extrasystemic cause variation, in performance results from assignable causes. Special-cause variation is intermittent, unpredictable, and unstable. It is not inherently present in a system; rather, it arises from causes that are not part of the system as designed.
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