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Glossary

Administration error: A medication dosage that is given to the patient in error, usually by the direct caregiver.
Adverse Drug Experience (ADE): An injury caused by the use of medications, or the failure to use appropriate medications when indicated, rather than the patient’s underlying condition.
Barcode: A machine-readable graphic representation, in the form of bars and spaces of varying width, of numeric or alphanumeric data. Scanning a bar code gives instant access to information in an associated database.
Barcode-enabled point of care (BPOC): Access to bar coding at the location of patient care delivery.
Computerized physician order entry (CPOE): An electronic prescribing system that intercepts errors at the time when medications are ordered. Physicians enter orders into a computer rather than on paper. Orders are integrated with patient information, including laboratory and prescription data. The order is then automatically checked for potential errors or problems.
Dispensing error: A deviation from the prescriber’s order, made by the staff in the pharmacy when distributing medication to nursing units or to patients in ambulatory settings.
Error: The failure of a planned action to be completed as intended (eg, an error of execution) or use of a wrong plan to achieve an aim (eg, error of planning). The accumulation of errors results in accidents.
Failure mode: A way in which a process or sub-process can fail to provide the anticipated result.
Failure mode analysis: Examining a product or system to identify all the ways in which it might fail.
Forcing function: A technique that reduces the possibility that a medication will be administered in a potentially lethal manner (eg, using oral syringes for oral liquid doses that will not fit with IV tubing and to which needles cannot be attached; and CPOE, which can be used to "force" physicians to order standardized products).
Healthcare Failure Modes and Effects Analysis (HFMEA): A prospective assessment developed by the VA National Center for Patient Safety that identifies and improves steps in a process, thereby reasonably ensuring a safe and clinically desirable outcome. It combines the detectability and criticality steps of the traditional FMEA into an algorithm presented as a decision tree.
High-alert medication: A medication that has a heightened risk of causing injury when misused. Examples include heparin, warfarin, insulin, chemotherapy, concentrated electrolytes, IV digoxin, opiate narcotics, neuromuscular blocking agents, thrombolytics, and adrenergic agonists.
Human factors engineering: A discipline that seeks to improve human performance in the use of equipment by means of hardware and software design compatible with the abilities of the user population.
Infusion: The slow, prolonged injection of a fluid into the body.
Infusion pump: A device used to pump fluids into a patient in a controlled manner. The device may use a piston pump, roller pump, or a peristaltic pump and may be powered electrically or mechanically. The device may include means to detect a fault condition, such as air in, or blockage of, the infusion line and to activate an alarm.
Medication error: Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.
National Drug Code (NDC): The single basic identifier for all forms of pharmaceutical products in the health industry. Pharmacy computer systems, third-party prescription claims processing, and sales tracking, reporting, and industry support services all use the NDC to identify, describe, and pay for pharmaceutical services.
Near miss: An event or situation that could have resulted in an accident, injury, or illness, but did not, either by chance or through timely intervention. Also referred to as a "close call."
Patient safety: Freedom from accidental injuries during the course of medical care; activities to avoid, prevent, or correct adverse outcomes that may result from the delivery of health care.
Point of care: All patient encounters with clinicians, physicians, nurses, and pharmacists.
Prescribing error: A mistake made by the prescriber when ordering a medication (eg, miscalculation of a dose, misspelling of a drug name, choosing the wrong product for the diagnosis.)
Preventable adverse event: An adverse event that can be attributed to an error.
Root cause analysis: A process for identifying the basic or contributing causal factors that underlie variations in performance associated with adverse events or close calls.