Glossary

Possessing the knowledge and skills to practice clinically in accordance with the generally accepted standards of care.

An incident resulting in serious harm (loss of life, limb, or vital organ) to the patient, or the significant risk thereof. Incidents are considered critical when there is an evident need for immediate investigation and response.
(Royal College of Physicians and Surgeons, The Canadian Patient Safety Dictionary, 2003)

The process by which a patient safety incident is communicated to the patient by healthcare providers.
(Canadian Patient Safety Institute, Canadian Disclosure Guidelines, 2011)

• Initial disclosure: The initial communications with the patient as soon as reasonably possible after a patient safety incident, focusing on the known facts and the provision of further clinical care.
• Post-analysis disclosure: Subsequent communications with a patient about known facts related to (the harm and) the reasons for the harm after an appropriate analysis of the patient safety incident.

An act (plan, decision, choice, action or inaction) that when viewed in retrospect was not correct and resulted in a patient safety incident or a near miss.

The use of the term “error” should generally be avoided, especially before all the facts are known, because it can inappropriately suggest there was blameworthy conduct on the part of the healthcare provider. The term may be misunderstood to mean the care provided was substandard or negligent in law. Errors may or may not be the result of negligence.

Physicians are not necessarily in breach of their duty toward a patient simply because they have committed an error of judgment after a careful examination and thoughtful analysis of a patient’s condition. Errors in judgment may occur, for example, in diagnosing a condition or in choosing among different therapeutic approaches.

As used in patient safety, the components of a system or steps in a process for the provision of clinical care are studied prior to the occurrence of patient safety incidents (proactively) to determine the probability and impact of a failure in a component or step.

Impairment of structure or function of the body and/or any deleterious effect arising therefrom. Harm includes disease, injury, suffering, disability, and death.
(Canadian Patient Safety Institute, Canadian Disclosure Guidelines, 2011)

Knowing an undesirable outcome has occurred increases the belief that it was predictable, should have been foreseen and therefore was preventable.

A structured process that aims to identify what happened, how and why it happened, what can be done to reduce the risk of recurrence and make care safer, and what was learned.
(Canadian Patient Safety Institute. Canadian Incident Analysis Framework, 2012.)

A report of a patient safety incident or near-miss (sometimes called by other terms such as patient safety reports). The information contained therein may not be protected from disclosure.

A healthcare approach in which the provision of safe care is a core value of the organization. The culture encourages and develops the knowledge, skills and commitment of all leaders, management, healthcare professionals, staff, and patients for the provision of safe patient care. Opportunities to proactively improve the safety of care are constantly identified and acted on. Providers and patients are appropriately and adequately supported in the pursuit of safe care. The culture encourages learning from patient safety incidents and near-misses to strengthen the system, and where appropriate, supports and educates healthcare professionals and patients to help prevent similar events in the future. There is a shared commitment across the organization to implement improvements and to share the lessons learned. Justice is an important element. All are aware of what is expected, and when analyzing patient safety incidents any professional accountability of healthcare professionals is determined fairly. The interests of both patients and providers are protected.

A quality improvement activity in which the members of a hospital/institution department review the clinical care provided to a specific patient or group of patients in order to educate or increase awareness of all those involved and provide recommendations for improved care for all patients in the future.

Allegations of negligence or civil responsibility (in Québec) extend to acts the physician is said to have committed in error or steps it is suggested the physician should have taken but failed to take. In jurisdictions subject to common law (all provinces and territories except Québec), four elements must be established or proven for any legal action based on a claim for negligence to be successful:

1. There must be a duty of care owed to the patient.
2. There must be a breach of that duty of care.
3. The patient must have suffered some harm or injury.
4. The breach of the duty of care must have caused the harm or injury.

In Québec, the elements required to evaluate the liability are derived from different sources, but the issues to be decided by the court are similar.

The pursuit of reduction and mitigation of unsafe acts within the health care system, as well as the use of best practices shown to lead to optimal patient outcomes.
(Frank, JR, Brien, S, (Editors) on behalf of The Safety Competencies Steering Committee. The Safety Competencies: Enhancing Patient Safety Across the Health Professions. Ottawa, ON: Canadian Patient Safety Institute; 2008.)

An event or circumstance which could have resulted, or did result, in unnecessary harm to a patient. Includes:

• Harmful incident: A patient safety incident that resulted in harm to the patient. Replaces “adverse event” and “sentinel event.”
• No harm incident: A patient safety incident which reached a patient but no discernable harm resulted.
• Near miss: A patient safety incident that did not reach the patient. Replaces “close call.”

(Healthcare Excellence Canada. Engaging Patients in Patient Safety, Glossary of terms.)

A retrospective review by peers, or subject matter experts, of an individual or groups of individuals looking at specific indicators of quality of care. The goal is to identify, within a confidential process, areas for practice improvement. Under certain conditions, a peer review may be undertaken to assess the clinical competency of an individual.

An exception to the general rule in civil litigation that all relevant information in the possession, power or control of a party must be disclosed to all opposing parties. The law of privilege protects certain communications (whether written or oral) from disclosure in legal proceedings. A claim of privilege is also recognized as an exception to the provisions in provincial/territorial and federal privacy legislation that individuals have a general right of access to their personal information.

The legal concept that administrative proceedings should be conducted in a manner that is fair to the parties involved. While the extent of fairness varies with the nature of the proceedings, at minimum, affected parties should be given a fair opportunity to participate in the proceedings. This includes providing parties with notice of the proceedings and the ability to respond to any prejudicial argument or evidence.

The analysis by healthcare organizations (usually by a quality improvement committee) of patient outcomes, clinical practices, and systems of care in order to recommend improvements.

Quality improvement committees, as part of an ongoing program to improve patient care, should be structured under the relevant provincial/territorial legislation and include formal terms of reference. Quality improvement committees, depending on the province or territory, may have different titles, for example: Quality of Care, Critical Incident Review, Risk Management.

The communication of information about a patient safety incident by healthcare providers, through appropriate channels inside or outside of healthcare organizations, for the purpose of reducing the risk of occurrence of patient safety incidents in the future.
(Canadian Patient Safety Institute, Canadian Disclosure Guidelines, 2011)

A person who is legally authorized to make decisions on behalf of the patient. This authority may be granted by the patient themselves with a legal document such as an advance medical directive, by legislation in each province/territory or by the courts.

The lack of, malfunction or failure of policies, operational processes, or the supporting infrastructure for the provision of healthcare.

An approach to retrospective audit in which certain occurrences (e.g., readmission to hospital, abnormal laboratory values, or the use of certain medications) are used as indicators to identify possible patient safety incidents.