Glossary
Incident reporting, defined.
46 plain-language definitions of the terms used in incident reporting, QAPI, survey readiness and OSHA recordkeeping, with sources.
A
- AAAHCRegulatory and complianceAAAHC is a group that accredits, or formally approves, outpatient care sites like surgery centers and endoscopy centers. It began in 1979.
- Adverse eventHealthcare and patient safetyAn adverse event is patient harm caused by care, not by the illness. Groups define it a bit differently, so say which one you use.
- ASCQR (ASC Quality Reporting Program)Regulatory and complianceASCQR is the CMS quality reporting program for surgery centers. Centers that do not report take a 2.0 point cut in their Medicare payment update.
C
- CMS-2567Regulatory and complianceForm CMS-2567 lists each Medicare or Medicaid rule a provider missed. The provider replies on it with a plan to fix them. The public can see it.
- Conditions for coverageRegulatory and complianceConditions for coverage (CfCs) are health and safety rules for some Medicare suppliers, like surgery centers. Hospitals have CoPs, the same idea.
- Corrective and preventive actionQuality and improvementCAPA (corrective and preventive action) fixes the cause of a problem, then checks that the fix worked. Healthcare rules often say corrective action.
D
- DART rateEHS and workplace safetyThe DART rate counts OSHA cases with days away, restricted work or job transfer per 100 full-time workers. The formula is cases × 200,000 ÷ hours worked.
- Deemed statusRegulatory and complianceDeemed status means CMS lets a provider pass an outside group's survey in place of a state survey. The group must be one CMS has approved.
- DeficiencyRegulatory and complianceA deficiency is a failure to meet a Medicare or Medicaid rule. A surveyor, or inspector, lists it on Form CMS-2567 and nursing homes get a score.
E
- Effectiveness reviewQuality and improvementAn effectiveness review checks that a fix worked and the problem did not return. A measure and a date set in advance let the action close.
- ElopementHealthcare and patient safetyElopement is when a patient or resident slips out of a facility without staff knowing, when supervision is needed. CMS cites it at F689.
F
- F-tagRegulatory and complianceAn F-tag is a code CMS uses to cite nursing home survey findings, like F689 for accidents. Each tag links to a rule in 42 CFR Part 483.
- Fault tree analysisQuality and improvementFault tree analysis (FTA) starts from a bad outcome and maps the combinations of failures that could cause it. OSHA lists it for process hazard analysis.
- First aid (OSHA recordkeeping)EHS and workplace safetyFor OSHA recordkeeping, first aid is only the care on its closed list, like bandages or cleaning a wound. First aid alone is not recordable.
- Fishbone diagramQuality and improvementA fishbone diagram maps the possible causes of one problem on branches, like fish bones. Teams also call it a cause-and-effect or Ishikawa diagram.
- Five whysQuality and improvementFive whys is a way to find a root cause. Ask why a problem happened, then why again for each answer, until you reach a cause you can fix.
- FROI (First Report of Injury)EHS and workplace safetyFROI, the First Report of Injury, is the first report of a work injury sent to the workers' compensation insurer. It opens the claim.
H
- Harm scaleHealthcare and patient safetyA harm scale ranks how much harm an event caused, from none up to death. No scale is universal. Common ones are the NCC MERP index and the CMS grid.
- Hierarchy of controlsEHS and workplace safetyThe hierarchy of controls ranks ways to reduce a hazard, from strongest to weakest. NIOSH puts removing the hazard first and protective gear last.
I
- Immediate jeopardyRegulatory and complianceImmediate jeopardy (IJ) means a provider's failure has caused, or will likely cause, serious harm or death. It is the most serious kind of deficiency.
- Incident reportQuality and improvementAn incident report is a written record of an unplanned event that hurt, or could have hurt, a person or property. It starts the review.
J
- Joint CommissionRegulatory and complianceThe Joint Commission is a US group that accredits hospitals, outpatient, nursing care and home care sites. It also sets the Sentinel Event Policy.
- Just cultureQuality and improvementJust culture is a safety approach that treats honest error, risky shortcuts and reckless acts differently. Staff can report mistakes without fear.
L
- Lockout/tagoutEHS and workplace safetyLockout/tagout (LOTO) means cutting a machine's power and locking or tagging the switch before repairs. OSHA's standard is 29 CFR 1910.147.
- Lost-time injuryEHS and workplace safetyA lost-time injury is a work injury or illness that keeps a worker home past the day it happened. OSHA's term for it is a days-away case.
- LTIR (lost-time injury rate)EHS and workplace safetyLTIR (lost-time injury rate) counts injuries that cost workdays per set block of hours. OSHA does not use the term, so confirm the formula before you compare.
N
- Near missQuality and improvementA near miss is an event that could have hurt someone but did not. Someone caught it in time, or it missed by chance. OSHA calls it a close call.
- Never eventHealthcare and patient safetyNever events are serious patient safety events that should never happen, like surgery on the wrong body part. The NQF list has 29 of them.
P
- Patient safety organizationRegulatory and complianceA patient safety organization (PSO) is a group HHS lists to collect and study safety data. Data sent to it can be legally protected.
- Performance improvement projectQuality and improvementA performance improvement project (PIP) is a focused effort to fix one specific problem. It uses data to find causes, test changes and measure results.
- Plan of correctionRegulatory and complianceA plan of correction (PoC) is a provider's written answer to survey findings. It says how and by when the facility will fix each problem and keep it fixed.
- Pressure injuryHealthcare and patient safetyA pressure injury is skin and tissue damage from steady pressure, often over a bone. CMS treats it as the same as a pressure ulcer and cites F686.
- Protected health information (PHI)Regulatory and complianceProtected health information (PHI) is health data that identifies a person. HIPAA covers it when a provider, plan or their vendor holds it.
- PSIF (potential serious injury or fatality)EHS and workplace safetyPSIF means potential serious injury or fatality: an event that could have caused death or life-changing harm. It is a safety term, not an OSHA category.
Q
- QAA committeeRegulatory and complianceThe QAA (quality assessment and assurance) committee runs a nursing home's QAPI quality program. It meets at least every quarter, as CMS requires.
- QAPIRegulatory and complianceQAPI (quality assurance and performance improvement) is the quality program CMS requires. Providers use data to track harm and fix root causes.
R
- Risk matrixQuality and improvementA risk matrix scores a hazard by crossing how bad the outcome could be with how likely it is. The score sets which problems to fix first.
- Root cause analysisQuality and improvementRoot cause analysis (RCA) finds why a serious event happened, so fixes hit causes, not symptoms. It looks at the system, not at blame.
S
- Safety data sheetEHS and workplace safetyA safety data sheet (SDS) is a 16-section document on a chemical's hazards and safe handling. Employers must keep one for each hazardous chemical they use.
- Sentinel eventHealthcare and patient safetyA sentinel event is a patient safety event that reaches a patient and causes death, severe harm or permanent harm. That is the Joint Commission's meaning.
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