Patient Safety - Health Committee Contents


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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Prepared 3 July 2009