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Caregiver

A family member, friend, or other person not providing patient care on behalf of the healthcare facility, who is assisting the patient with medication administration, particularly in the home, or monitoring the patient’s adherence to instructions.

Close call

An error that was detected and corrected before it reached the patient (sometimes referred to as a “near miss”).

Guideline

Recommendations that provide acceptable practices and options, including drug therapy, for managing a particular procedure or treatment for a specific diagnosis or condition, which can be used to assist in clinical decision making and adapted to the patient’s specific needs.

High-alert medications (or drugs)

 Medications that bear a heightened risk of causing significant patient harm when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error are more devastating to patients. Examples of high-alert medications include insulin, opioids, neuromuscular blocking agents, anticoagulants, and many others. A complete list of high-alert medications used in the acute care setting (also appropriate for outpatient perioperative care settings) can be found at: www.ismp.org/node/103. 

Medical and/or surgical procedure

 Any medical and/or surgical procedure performed on a patient by a licensed healthcare practitioner that requires moderate sedationA drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. MODERATE SEDATION should be performed by a qualified individual, separate from the proceduralist, so that vital functions can be continuously monitored and supported., deep sedationA drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained., monitored anesthesia care (MAC)A specific anesthesia service used for medical and/or surgical procedures in which a qualified ANESTHESIA PROVIDER continually monitors and supports the patient’s vital functions; diagnoses and treats clinical problems that occur; administers sedative, anxiolytic, or analgesic medications to achieve varying levels of sedation, awareness, and analgesia; and converts to GENERAL ANESTHESIA if required., regional anesthesiaRefers to peripheral nerve blocks as well as all NEURAXIAL ANESTHESIA, including EPIDURAL ANESTHESIA and SPINAL ANESTHESIA., and/or general anesthesiaA drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired., including diagnostic and invasive proceduresA procedure that penetrates the protective surfaces of a patient’s body, generally requiring entry into a body cavity and/or insertion of an indwelling foreign body; is performed in an aseptic surgical field; and requires MODERATE SEDATION, DEEP SEDATION, MAC, REGIONAL ANESTHESIA, and/or GENERAL ANESTHESIA of the patient to perform. Procedures that do not require sedation or anesthesia as listed above are not included in this definition. that meet this definition.

Medication (or drug)

Medication includes: prescription medications; sample medications; herbal remedies; vitamins; nutraceuticals; over-the-counter drugs; vaccines; diagnostic and contrast agents used on or administered to persons to diagnose, treat, or prevent disease or other abnormal conditions; radioactive medications; respiratory therapy treatments; parenteral nutrition; blood derivatives; IV solutions (plain, with electrolytes and/or drugs); and any product designated by the US Food and Drug Administration (FDA) as a drug. The definition of medication does NOT include enteral nutrition solutions (which are considered food products); oxygen and other medical gases; and illicit drugs unless explicitly stated.

Neonate (or neonatal)

 A newborn infant up to and including 1 month old.

Order set

Standardized list or template of logically grouped medical orders used to treat specific clinical situations (e.g., a specific diagnosis, a specific drug therapy), which follow pre-established clinical guidelines based on evidence-based best practices. The use of order sets can decrease variation in care; enhance compliance with recommended treatment guidelines; promote complete, unambiguous, and accurate orders; reduce the risk of prescribing errors; and improve patient outcomes.

Pediatric

An infant older than 1 month to children and adolescents up to young adulthood.

Perioperative

The preoperative, intraoperative/intraprocedural, and postoperative phases of a medical and/or surgical procedure, extending from the time a patient is prepared for a procedure until he or she is discharged home after the procedure or transferred out of the perioperative setting, usually to an inpatient bed.

Practitioner

A licensed healthcare professional who is authorized within the institution to prescribe, dispense, or administer medications, such as a physician, physician assistant, CRNA, certified anesthesiologist assistant, nurse practitioner, nurse (including circulating nurse, scrub nurse), perfusionist, pharmacist, or respiratory therapist.
 

Protocol

A defined, standard regimen intended to be followed for managing a particular procedure, drug therapy, or treatment for a specific diagnosis or condition, which often includes medication precautions and dosing instructions, supportive treatments, and patient monitoring.