Appendix 5 Glossary
Below are some key clinical terms that are found throughout safety and quality standards and in health service settings.
Acute deterioration general/mental state
A physiological, psychological or cognitive change that may indicate a worsening of the patient’s health status; this may occur across hours or days.32
Adverse event
An incident that results, or could have resulted, in harm to a patient or consumer. A ‘near miss’ is a type of adverse event.33
Clinical governance
Clinical governance is an integrated component of the corporate governance of health service organisations. It ensures that everyone—from frontline clinicians to managers and members of governing bodies such as boards—is accountable to patients and the community for assuring the delivery of safe, effective and high-quality services. Clinical governance systems provide confidence to the community and the healthcare organisation that systems are in place to deliver safe, high-quality health care.34
Clinical handover
Clinical handover is the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis.35
Complaint
An expression of dissatisfaction made to or about an organisation that is related to its products, services, staff or handling of a complaint, for which a response or resolution is explicitly or implicitly expected or legally required.36
Complaints management system
Encompasses all aspects of the policies, procedures, practices, staff, hardware and software used by the organisation to manage complaints.37
Critical incident
Any unintended event that occurs when a patient receives treatment in a hospital that (a) results in death, or serious disability, injury or harm to the patient, and (b) does not result primarily from the patient’s underlying medical condition or from a known risk inherent in providing the treatment.38
De-escalation strategies
Psycho-social techniques that aim to reduce violent or disruptive behaviour. They are intended to reduce or eliminate the risk of violence during the escalation phase by using verbal and non-verbal communication skills. De-escalation is about establishing rapport to gain the patient’s trust, minimising restriction to protect their self-esteem, appearing externally calm and self-aware in the face of aggressive behaviour, and intuitively identifying creative and flexible interventions that reduce the need for aggression.39
Escalation of care
An intervention whereby a patient or family member is assisted within a hospital setting to raise concerns with healthcare professionals to assess and respond to clinical deterioration that they are worried about.40
Health literacy
The Australian Commission on Safety and Quality in Health Care separates health literacy into two components: individual health literacy and the health literacy environment. Individual health literacy is the skills, knowledge, motivation and capacity of a consumer to access, understand, appraise and apply information to make effective decisions about health and health care, and take appropriate action. The health literacy environment is the infrastructure, policies, processes, materials, people and relationships that make up the healthcare system and affect the ways in which consumers access, understand, appraise and apply health-related information and services.41
Medication reconciliation
Medication reconciliation is the formal process of obtaining and verifying a complete and accurate list of a patient’s current medicines, and matching the medicines the patient should be prescribed to those they are actually prescribed. Any discrepancies are discussed with the prescriber, and reasons for changes to therapy are documented and communicated when care is transferred. Medication review may form part of the medication reconciliation process.42
Open disclosure
Open disclosure involves an open discussion with a patient and their carer about an incident that resulted in harm to the patient while receiving health care. The criteria of open disclosure are an expression of regret, a factual explanation of what happened, the potential consequences, and the steps taken to manage the event and prevent recurrence.43
Quality improvement
Quality improvement involves the combined efforts of the workforce and others—including consumers, patients and their families, researchers, planners and educators–to make changes that will lead to better patient outcomes (health), better system performance (care) and better professional development. Quality improvement activities may be undertaken in sequence, intermittently or continually.44
Restrictive practices
Restrictive practices involve the use of interventions and practices that have the effect of restricting the rights or freedom of movement of a person. These primarily include restraint (chemical, mechanical, social or physical) and seclusion.45
Risk management system
Risk management system is the design and implementation of a program to identify and avoid or minimise risks to patients, employees, volunteers, visitors and the organisation.46
Risk screening
Risk screening is a short process to identify patients who may be at risk of, or already have, a disease or injury. It is not a diagnostic exercise, but rather a trigger for further assessment or action.47
Root cause analysis
A methd or methodology used to investigate an incident in order to assist in the identification of health system failures that may not be immediately apparent at initial review. It is interdisciplinary in nature and uses a structured process that endeavours to answer three questions: What happened? Why did it happen? How can it be prevented from occurring again?48
Transitions of care
Situations when all or part of a patient’s care is transferred between healthcare locations, providers, or levels of care within the same location, as the patient’s conditions and care needs change.50
