GLOSSARY

Adverse event

An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient.

Adverse event triggers

Clinical data related to patient care indicating a reasonable probability that an adverse event has occurred or is occurring. An example of trigger data for an adverse drug event is a physician order for an antidote, a medication stop, or a dose decrease.

Alert message

A computer-generated output that is created when a record meets prespecified criteria; for example, receipt of a new laboratory test result with an abnormal value (Shortliffe et al., 2001).

Assertional knowledge

Primitive knowledge that cannot be defined from other knowledge.

Authentication

A process for positive and unique identification of users, implemented to control system access (Shortliffe et al., 2001).

Case-based reasoning

A decision support system that uses a database of similar cases (van Bemmel, 1997).

Causal continuum assumption

The assumption that the (failure) causal factors of consequential accidents are similar to those of nonconsequential near misses.

Chart review

The retrospective review of the patient's complete written record by an expert for the purpose of a specific analysis. For patient safety, to identify possible adverse events by reviewing the physician and nursing progress notes and careful examination for certain indicators.

Classification

A taxonomy that arranges or organizes like or related terms for easy retrieval (National Committee on Vital and Health Statistics, 2000).

Clinical data repository

Clinical database optimized for storage and retrieval for information on individual patients and used to support patient care and daily operations (Shortliffe et al., 2001).

Clinical Document Architecture

A document markup standard that specifies the structure and semantics of “clinical documents” for the purpose of exchange (Van Hentenryck, 2001).

Clinical domain

A clinical area of interest that might be modeled for a clinical information system. (van Bemmel, 1997)

Clinical event monitor

Rule-based programs that sit atop a clinical data repository, supporting real-time error prevention.

Clinical information systems

The components of a health care information system designed to support the delivery of patient care, including order communications, results reporting, care planning, and clinical documentation (Shortliffe et al., 2001).

Close call

An event or situation that could have resulted in an adverse event but did not, either by chance or through timely intervention (U.S. Department of Veterans Affairs, 2002).

Code

A numeric or alphanumeric representation assigned to a term so that it may be more readily processed (National Committee on Vital and Health Statistics, 2000).

Comparability

Ability to compare similar data held in different computer systems. Comparability requires that the meaning of data is consistent when shared among different parties (National Committee on Vital and Health Statistics, 2000).

Computer detection rules

Boolean combinations of medical events, for example, new medication orders and laboratory results outside certain limits that suggest an adverse drug event might be present.

Computerized physician order entry (CPOE)

Clinical systems that utilize data from pharmacy, laboratory, radiology, and patient monitoring systems to relay the physician's or nurse practitioner's diagnostic and therapeutic plans and alert the provider to any allergy or contraindication that the patient may have so that the order may be immediately revised at the point of entry prior to being forwarded electronically for the targeted medical action (First Consulting Group, 2003).

Concept orientation

Elements of the terminology are coded concepts, with possibly multiple synonymous text representations and hierarchical or definitional relationships to other coded concepts. No redundant, ambiguous, or vague concepts exist (Sujansky, 2003).

Concept permanence

The meaning of each coded concept in a terminology remains forever unchanged. If the meaning of a concept needs to be changed or refined, a new coded concept is introduced. No retired codes are deleted or reused (Sujansky, 2003).

Conceptual model

A model of the main concepts of a domain and their relationships (van Bemmel, 1997).

Consistency of views

Consistency of views says that concepts in multiple classes have the same appearance in each context (e.g., corticosteroid as hormone or antiinflammatory agent has the same attributes and descendant concepts).

Data acquisition

The input of data into a computer system through direct data entry, collection from a medical device, or other means (Shortliffe et al., 2001).

Data element

The basic unit of information having a unique meaning and subcategories of distinct units or values (van Bemmel, 1997).

Data interchange standards

Syntactic and semantic rules for defining data elements and which govern the seamless communication between computer systems while preserving the meaning of the data and intended functions.

Data mining

The use of a basic set of tools to extract patterns from the data in a data warehouse (van Bemmel, 1997).

Data set

A group of data elements specifically selected for a particular clinical purpose, such as clinical quality measurement, patient safety reporting, etc.

Data type

Defines how a data element is formatted or expressed. Simple data types include date, time, numeric, string, blob (large binary objects, such as images), currency, or coded element; complex data types include a structure for names, addresses, etc. (Hammond, 2002).

Data warehouse

Database optimized for long-term storage, retrieval, and analysis of records aggregated across patient populations, often serving the longer term business and clinical analysis needs of an organization. (Shortliffe et al., 2001).

Decision support systems

A system consisting of a knowledge base and an inference engine that is able to use entered data to generate advice (van Bemmel, 1997).

Decision trees

A diagrammatic representation of the outcomes associated with chance events and voluntary actions (Shortliffe et al., 2001).

Default reasoning

Drawing of plausible inferences on the basis of less than conclusive evidence in the absence of information to the contrary.

Definitional knowledge

Knowledge that can be defined or constructed from other knowledge.

Domain completeness

Domain completeness must not restrict terminology size through presuppositions about ultimate dimensions (e.g., no preset coding system that restricts depth or breadth of the hierarchy).

Electronic health record

A repository of electronically maintained information about an individual's health care and corresponding clinical information management tools that provide alerts and reminders, linkages with external health knowledge sources, and tools for data analysis (Shortliffe et al., 2001).

Encryption

The process of encoding (scrambling) data such that a specific key is needed to decode the data. Most methods are based on the use of prime numbers (van Bemmel, 1997).

Error

The failure of a planned action to be completed as intended (i.e., error of execution), and the use of a wrong plan to achieve an aim (i.e., error of planning) (Institute of Medicine, 2000). It also includes failure of an unplanned action that should have been completed (omission).

Evidence

Scientific evidence is a replicable and generalizable observation that can be experienced nearly identically by independent people from different places and at different times.

Evidence-based guidelines

Consensus approaches for handling recurring health management problems aimed at reducing practice variability and improving health outcomes. Guideline development emphasizes using clear evidence from the existing literature, rather than expert opinion alone, as the basis for advisory materials (Shortliffe et al., 2001).

Explicit relationships

The relationships between concepts in a hierarchy are clearly defined (e.g., relationship between staphylococcal pneumonia and pneumonia is differentiated from relationship between staphylococcal pneumonia and staphylococcus, where the former is a class relation and the latter is an etiologic relation).

Extensible markup language (XML)

A specification designed specifically for Web documents. It allows designers to create their own customized tags to provide functionality not available with HTML (Newton, 2001).

Health care terminology

A collective term used to describe the continuum of code set, classification, and nomenclature (vocabulary) (National Committee on Vital and Health Statistics, 2000).

Iatrogenic injury

Injury originating from or caused by a physician (iatros, Greek for “physician”), including unintended or unnecessary harm or suffering arising from any aspect of health care management, including problems arising from acts of commission or omission.

Informatics

The science that studies the use and processing of data, information, and knowledge (van Bemmel, 1997).

Interoperability

The ability of one computer system to exchange data with another computer system such that, at a minimum, the message from the sending system can be placed in the appropriate place in the receiving system (National Committee on Vital and Health Statistics, 2000).

Interpreter

A component of production rule system deciding which rule to execute on each selection execute cycle.

Judgment

A discriminating or authoritative appraisal, opinion, or decision, based on sound and reasonable evaluation.

Knowledge base

A collection of systematically stored facts, heuristics, and models that can be used to make decisions or solve problems (Shortliffe et al., 2001).

Knowledge representation

Expresses medical knowledge in computer-tractable form.

Knowledge representation formalism

Formalism used to express knowledge. Also known as knowledge representation language.

Knowledge representation language

Formalism used to express knowledge. Also known as knowledge representation formalism.

Levels of evidence

It is widely recognized that various scientific methodologies produce various levels of evidence, that is, chances of identical experience when replicated by independent observers. In the testing of presumably beneficial health care interventions, the multicenter randomized controlled clinical trial is widely regarded as the top-quality source due to the demonstrable weaknesses of alternative methodologies. Randomized trials are central to Food and Drug Administration drug approval, strongly preferred information sources by most clinical practice guidelines, and prominently featured by the international Cochrane collaboration. When randomization is not possible or randomized controlled trial results are not available, original research data from controlled observations represent the next best choice (e.g., linking risky behaviors to adverse effects).

Links

Components of semantic nets representing relationships between objects.

Mandatory reporting

Those patient safety reporting systems that by legislation and/or regulation require the reporting of specified adverse events, generally events of serious harm and death.

Mapping

The process of cross-linking terms from different terminologies so that comparisons and analyses can be undertaken.

Multiple classification

Multiple classification must not restrict terminology such that a concept is prevented from being assigned to as many classes as required (e.g., “viral pneumonia” can be in classes “pneumonia” and “viral diseases”).

National Health Information Infrastructure (NHII)

A set of technologies, standards, applications, systems, values, and laws that support all facets of individual health, health care, and public health (National Committee on Vital and Health Statistics, 2001).

Natural language processing (NLP)

Accessing data in the narrative form or free text and creating machine-understandable interpretations of those data (van Bemmel, 1997).

Near miss

An error of commission or omission that could have harmed the patient, but serious harm did not occur as a result of chance (e.g., the patient received a contraindicated drug but did not experience an adverse drug reaction), prevention (e.g., a potentially lethal overdose was prescribed, but a nurse identified the error before administering the medication), or mitigation (e.g., a lethal drug overdose was administered but discovered early and countered with an antidote).

Neural networks

A system in hardware or software of interconnected nodes developed in analogy with the human brain (van Bemmel, 1997).

Nodes

Components of semantic nets representing objects or classes of objects.

Nomenclature

A nomenclature, or vocabulary, is a set of specialized terms that facilitate precise communication by eliminating ambiguity (National Committee on Vital and Health Statistics, 2000).

Nonambiguity

Nonambiguity says that concepts must have exactly one meaning and, where a common term has two or more associated meanings (homonymy), they must be disambiguated into distinct concepts (e.g., “Paget disease” must be split into “Paget disease of the bone” and “Paget disease of the breast”) (Cimino, 1998).

Nonredundancy

Nonredundancy says that a mechanism must exist that can help prevent multiple terms for the same concept from being added to the terminology as unique concepts.

Nonvagueness

Nonvagueness says that concepts in the terminology must be complete in meaning (e.g., “ventricle” is not usually considered a fully described concept, nor does it represent some generic class of anatomic terms, i.e., it means neither “heart ventricle” nor “brain ventricle” when taken out of context).

Notational aspect of knowledge representation language

The way in which information is stored in an explicit format. Also known as syntactic aspect of knowledge representation language.

Patient safety

The prevention of harm caused by errors of commission and omission.

Procedural knowledge

Knowledge of how other than that.

Proof theory

A component of logic system that is a formal specification of the notion of correct inference.

Recovery

An informal set of human factors that lead to a risky situation being detected, understood, and corrected in time, thus limiting the sequence to a near-miss outcome, instead of it developing further into possibly an adverse event.

Reference terminology

Concept-oriented terminologies possessing characteristics such as a grammar that defines the rules for automated generation and classification of new concepts as well as combination of atomic concepts to form molecular expressions (Spackman et al., 1997).

Reporting formats

Sets of data elements required for reporting purposes.

Root-cause analysis

A process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event. Typically, the analysis focuses primarily on systems and processes, not individual performance (Joint Commission on Accreditation of Healthcare Organziations, 2003).

Rule base

A component of production rule system that represents knowledge as “if-then” rules.

Safe care

Safe care involves making evidence-based clinical decisions to maximize the health outcomes of an individual and to minimize the potential for harm. Both errors of commission and omission should be avoided.

Safety incident

Defined by the National Research Council as an event that, under slightly different circumstances, could have been an accident.

Semantics

Components of logic system that specify the meanings of the well-formed expressions of the logical language.

Slots

Components of the frame system that describe objects.

Soundness

A property of logic system that every sentence derived from a set of sentences is also a valid consequence of that set of sentences.

Standards

A set of characteristics or quantities that describes features of a product, process, service, interface, or material. The description can take many forms, such as the definition of terms, specification of design and construction, detailing of procedures, or performance criteria against which a product, process, and other factors can be measured (National Research Council, 1995).

Surveillance

Routine collection and review of data to examine the extent of a disease, to follow trends, and to detect changes in disease occurrence, such as infectious disease surveillance, postmarketing surveillance, etc. (van Bemmel, 1997).

Synonomy

Synonomy supports multiple nonunique names for concepts.

Syntactic aspect of knowledge representation language

The way in which information is stored in an explicit format. Also known as notational aspect of knowledge representation language.

Syntax

The rules (grammar) for the description, storage, and transmission of messages or for the composition of a program statement (van Bemmel, 1997). The rules that specify the legal symbols and constructs of a language (Shortliffe et al., 2001).

Terminologies

Terminologies define, classify, and in some cases code data content.

User interface

A conceptual layer of a system architecture that insulates the programs designed to interact with users from the underlying data and the applications that process those data (Shortliffe et al., 2001).

Voluntary reporting

Those reporting systems for which the reporting of patient safety events is voluntary (not mandatory). Generally, reports on all types of events are accepted.

Working memory

A component of production rule system containing information that the system has gained about the problem thus far.

ACRONYM LIST

ADE

adverse drug event

AE

adverse event

AERS

Adverse Event Reporting System

AHRQ

Agency for Healthcare Research and Quality

AIMS

Australian Incident Monitoring System

AMI

acute myocardial infarction

ANSI

American National Standards Institute

ASC

Accredited Standards Committee

ASR

Alternative Summary Reporting—Medical Devices

ASTM

American Society for Testing and Materials

BPD

Blood Product Deviation Reporting System

CDA

Clinical Document Architecture

CDC

Centers for Disease Control and Prevention

CEN

Comité Européean Normalisation

CHF

congestive heart failure

CHI

Consolidated Health Informatics

CHIP

Children's Health Insurance Program

CIS

clinical information systems

CMS

Centers for Medicare and Medicaid Services

COPD

chronic obstructive pulmonary disease

CORAS

Risk Assessment of Security Critical Systems

CPOE

computerized physician order entry

CPT

Current Procedural Terminology

CQI

continuous quality improvement

CQuIPS

Center for Quality Improvement and Patient Safety

DHHS

Department of Health and Human Services

DICOM

Digital Imaging and Communications in Medicine

DoD

Department of Defense

DQIP

Diabetes Quality Improvement Project

DSM

Diagnostic and Statistical Manual

DSN

Dialysis Surveillance Network

E-Codes

External Causes and Injury Codes

EPC

Evidence-based Practice Center

ESRD

end-stage renal disease

FACCT

Foundation for Accountability

FCG

First Consulting Group

FDA

Food and Drug Administration

FMEA

failure mode and effect analysis

GELLO

Guideline Expression Language, Object Oriented

GLIF

Guideline Interchange Format

GP

general practitioner

GRM

Generic Reference Model

HACCP

hazard analysis and critical control points

HAZOP

hazard and operability studies

HCFA

Health Care Financing Administration

HCPCS

Health Care Financing Administration Common Procedure Coding System

HFMEA

Healthcare failure mode and effect analysis

HHCC

Home Health Care Classification

HIMSS

Healthcare Information Management Systems Society

HIPAA

Health Insurance Portability and Accountability Act of 1996

HL7

Health Level Seven

ICD–9 CM

International Classification of Diseases, Ninth Edition, Clinical Modification

ICD–10

International Classification of Diseases, Tenth Edition

ICD–O

International Classification of Diseases, Oncology

ICF

International Classification of Functioning, Disability and Health

ICNP

International Classification of Nursing Practice

ICPC

International Classification of Primary Care

IEEE

Institute of Electrical and Electronics Engineers

IHE

Integrating the Healthcare Enterprise

IOM

Institute of Medicine

ISMP

Institute for Safe Medication Practice

ISO

International Organization for Standardization

IT

information technology

JAMIA

Journal of American Informatics Association

JCAHO

Joint Commission on Accreditation of Healthcare Organizations

LOINC

Logical Observation Identifiers, Names and Codes

MAUDE

Manufacture and User Data Experience-Medical Devices

MDS

Minimum Data Set for Nursing Home Care

MedDRA

Medical Dictionary for Drug Regulatory Affairs

MedSun

Medical Product Surveillance Network

MER

Medication Errors Reporting

MERS TM

Medical Event Reporting System for Transfusion Medicine

MeSH

Medical Subject Headings

MHS PSP

Military Health System Patient Safety Program

MPSMS

Medicare Patient Safety Monitoring System

MRI

magnetic resonance imaging

NANDA

North American Nursing Diagnosis Association

NASA

National Aeronautics and Space Administration

NaSH

National Surveillance System for Health Care Workers

NASHP

National Academy for State Health Policy

NCHS

National Center for Health Statistics

NCPDP

National Council for Prescription Drug Programs

NCPS

National Center for Patient Safety

NCQA

National Committee for Quality Assurance

NCVHS

National Committee on Vital and Health Statistics

NDC

National Drug Code

NDF RT

National Drug File Clinical Drug Reference Terminology

NEDSS

National Electronic Disease Surveillance System

NEMA

National Equipment Manufacturers Association

NHII

national health information infrastructure

NHSN

National Healthcare Safety Network

NIC

Nursing Intervention Classification

NLM

National Library of Medicine

NLP

natural language processing

NM

near miss

NNIS

National Nosocomial Infections Surveillance

NOC

Nursing Outcomes Classifications

NPSF

National Patient Safety Foundation

NPV

negative predictive value

NQF

National Quality Forum

NRC

National Research Council

NYPORTS

New York Patient Occurrence Reporting and Tracking System

OASIS

Outcome and Assessment Information Set for Home Care

PATH

Program for Appropriate Technology in Health

PCDS

Patient Care Data Set

PCP

primary care physician

PHA

proactive hazard analysis

PMRI

patient medical record information

PNDS

Perioperative Nursing Data Set

PPV

positive predictive value

PQI

prevention quality indicator

PRA

probabilistic risk assessment

PS

patient safety

PSDS

patient safety data standards

PSRS

patient safety reporting system

QIPS

quality indicators for patient safety

QuIC

Quality Interagency Coordination Task Force

RCA

root-cause analysis

R-Demo

reporting demonstration

RIM

Reference Information Model

RSNA

Radiological Society of North America

RxNORM

normalized notations for clinical drugs

SAC

Safety Assessment Code

SNAEMS

Special Nutritionals Adverse Event Monitoring System

SNOMED CT

Systemized Nomenclature for Human and Veterinary Medicine, Clinical Terms

SPARCS

Statewide Planning and Research Cooperative System

TPS

Toyota Production System

TQM

total quality management

UCSF

University of California, San Francisco

UHI

universal health identifier

UMDNS

Universal Medical Device Nomenclature System

UMLS

Unified Medical Language System

USP

United States Pharmacopeial Convention, Inc.

VAERS

Vaccine Adverse Event Reporting System

VHA

Veterans Health Administration

VSD

Vaccine Safety Datalink

WONCA

World Organization of National Colleges, Academies, and Academic Associations of General Practitioners and Family Physicians

XML

extensible markup language

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