Glossary
A&E Accident and Emergency
ACC Accident Compensation Corporation (New
Zealand)
AIDC Automatic Identification and Data Capture
AvMA Action against Medical Accidents
CHCs Community Health Councils (1974-2003)
CHI Commission for Health Improvement (2000-4)
CMO Chief Medical Officer
CNO Chief Nursing Officer
CNST Clinical Negligence Scheme for Trusts
CQC Care Quality Commission
CQUIN Commissioning for Quality and Innovation
DH Department of Health
HCAIs Healthcare Associated Infections
HCC Healthcare Commission (2004-9)
HDC Health and Disability Commissioner (New
Zealand)
ICAS Independent Complaints Advocacy Services
MaPSaF Manchester Patient Safety Framework
NAO National Audit Office
NHSLA NHS Litigation Authority
NPSA National Patient Safety Agency
NQB National Quality Board
NRLS National Reporting and Learning System
PAC House of Commons Committee of Public
Affairs
PALS Patient Advice and Liaison Services
PCT Primary Care Trust
PROMs Patient-reported outcome measures
PSAT Patient Safety Action Team
PSO Patient Safety Observatory
SHA Strategic Health Authority
SPI Safer Patients Initiative
STEIS Strategic Executive Information System
SUI Serious Untoward Incident
WHO World Health Organization
Adverse event: An incident in which a patient is
harmed.
Clinical governance: The system through which NHS
organisations are accountable for continuously improving the quality
of their services and safeguarding high standards of care, by
creating an environment in which clinical excellence will flourish.
Fair blame culture: A culture in which healthcare
workers feel able to report and discuss harm to patients in which
they have been involved without fearing that they will be unfairly
blamed.
Human Factors: Environmental, organisational and
job factors, and human and individual characteristics which influence
behaviour at work in a way which can affect health and safety.
Often used as a synonym for non-technical skills (see below).
"Lean" thinking: The philosophy of empowering
and motivating shop-floor staff to streamline and improve processes,
reduce waste, improve quality, and deliver products and services
in a more timely way.
Near miss: A situation in which an event or omission,
or a sequence of events or omissions, arising during clinical
care fails to develop further, whether or not as the result of
compensating action, thus preventing injury to a patient.
Non-technical skills: The cognitive and social skills
(complementing technical skill, such as clinical skills in healthcare)
that allow people working in safety-critical industries to function
effectively and safely.
Patient safety: Freedom, as far as possible, from
harm, or risk of harm, caused by medical management, as opposed
to harm caused by the natural course of the patient's original
illness or condition.
Patient safety incident: Any unintended or unexpected
incident due to medical management, rather than the natural course
of the patient's original illness or condition, which could have
led or did lead to harm for one or more patients receiving NHS-funded
healthcare.
Productive Ward: A scheme for involving frontline
staff in designing and implementing more efficient ways of working,
bypassing conventional management chains of command.
Root-cause analysis: An investigative method that
seeks to identify the underlying causes of an incident, with a
view to preventing repetition.
Safer Patients Initiative: A UK-wide project, established
by the Health Foundation (an independent charity), to test and
implement ways of improving patient safety in acute hospitals.
Safety-critical industries: Those industries in which
failure can cause serious injury or death.
Sentinel event: An incident that signals the need
for immediate investigation and response, since it involves death
or other serious injury, or the risk of these.
Serious Untoward Incident: Something out of the ordinary
or unexpected, with the potential to cause serious harm, and /
or likely to attract public and media interest that occurs on
NHS premises or in the provision of an NHS or a commissioned service.
Significant Event Audit: A process through which
individual episodes in which there has been a significant occurrence,
either beneficial or deleterious, are analysed in a systematic
and detailed way to ascertain what can be learnt about the overall
quality of care and to indicate changes that might lead to future
improvements.
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