Wichtige englische Begriffe

Random event that is unforeseen, unfortunate and unexpected.

Active Error
Active errors occur at the level of the frontline provider (such as administration of wrong dose of a medication) and they are easier to measure because they are limited in time and space.

Adverse Event (AE)
An incident in which harm resulted to a person receiving health care.

Adverse Drug Event (ADE)
Any noxious and unintended effect of drug that occurs at doses used in human for prophylaxis, diagnosis, or treatment.

Classification (of medical error)
Classifications of medical error include:

  • Type of health care service provided (e. g., classification of medication errors by the National Coordinating Council for Medication Error Reporting and Prevention).
  • Severity of the resulting injury (e. g., sentinel events, defined as "any unexpected occurrence involving death or serious physical or psychological injury" by the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]).
  • Legal definition (e. g., errors resulting from negligence).
  • Type of setting (e. g., outpatient clinic, intensive care unit).
  • Type of individual involved (e. g., physician, nurse, patient).

An adverse patient event related to medical intervention.

An error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems.

Error Reporting System
Errors witnessed or committed by health care providers may be reported via structured data collection systems. Reporting systems, including surveys of providers and structured interviews, are a way to involve providers in research and quality improvement projects.

Failure [active]
Active failures are unsafe acts or omissions committed by those whose actions can have immediate adverse consequences – pilots, surgeons, nurses etc. The term includes:

  • Action slips or failures, such as picking up the wrong syringe
  • Cognitive failures, such as memory lapses and mistakes through ignorance or misreading a situation
  • "Violations" — deviations from safe operating practises, procedures, or standards.

In contrast with errors, which arise primarily from informational problems (forgetting, inattention, etc.), violations are more often associated with motivational problems such as low morale, poor examples from senior staff, and inadequate management generally.

Failure [latent]
Latent failures stem from fallible decisions, often taken by people not directly involved in the workplace. In medicine, latent failures would be primarily the responsibility of management and of senior clinicians at those time when they take decisions on the organisation of their unit. Latent failures provide the conditions in which unsafe acts occur; these work conditions include:

  • Heavy workloads
  • Inadequate knowledge or experience
  • Inadequate supervision
  • A stressful environment
  • Rapid change within an organisation
  • Incompatible goals (for example, conflict between finance and clinical need)
  • Inadequate systems of communication
  • Inadequate maintenance of equipment and buildings.

These are the factors that influence staff performance and may precipitate errors and affect patient outcomes.

An event or circumstance resulting from health care which could have, or did lead to unintended and/or unnecessary harm to a person, and/or a complaint, loss or damage.

Latent Error
Latent errors include system defects such as poor design, incorrect installation, faulty maintenance, poor purchasing decisions and inadequate staffing. These are difficult to measure because they occur over broad ranges of time and space and they may exist for days, month or even years before they lead to more apparent error or adverse event directly related to patient care.

Medical Error
Medical error is defined as the failure of a planned action to be completed as intended (i. e., error of execution) or the use of a wrong plan to achieve an aim (error of planning).

Medication Error
Medication error is defined as a dose administered differently than ordered on the patient medical record, they are viewed as system defects. There are several categories defined as follows:

  • unauthorized drug
  • extra dose
  • wrong dose
  • omission
  • wrong route (i. e., orally instead of intramuscularly)
  • wrong form
  • wrong technique
  • wrong time.

Near Miss
A near miss is any event that could have had adverse consequences but did not and was indistinguishable from fully fledged adverse events in all but outcome.
Near misses offer powerful reminders of system hazards and retard the process of forgetting to be afraid.

Patient Safety
Patient safety is the avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the processes of health care. These events include "errors", "deviations" and "accidents". Safety emerges from the interaction of the components of the system; it does not reside in a person, device or department.  Improving safety depends on learning how safety emerges from the interactions of the components. Patient safety is a subset of healthcare quality.

Skill-based errors are called slips, they are unconscious glitches in automatic activity. Slips are errors of action, they occur when there is a break in the routine while attention is diverted.



Thomeczek C, Bock W, Conen D, Ekkernkamp A, Everz D, Fischer G, Gerlach F, Gibis B, Gramsch E, Jonitz G, Klakow-Frank R, Oesingmann U, Schirmer HD, Smentkowski U, Ziegler M, Ollenschläger G. Das Glossar Patientensicherheit. Ein Beitrag zur Definitionsbestimmung und zum Verständnis der Thematik "Patientensicherheit" und "Fehler in der Medizin".
Gesundheitswesen 2004;66(12):833-40.


zuletzt verändert: 15.10.2012 16:10