ACSR key terms

A defined work area where only sterile items and sterile-gloved personnel may contact surfaces, maintained to prevent microorganisms from entering a surgical or invasive site.

A set of practices and barriers used to keep equipment and the procedural area free of pathogens, reducing the risk of infection during invasive procedures.

The personal and professional standard of honestly reporting and correcting any break in sterile technique, even when no one else observed the lapse.

A patient's voluntary agreement to a procedure after receiving and understanding information about its purpose, risks, benefits, and alternatives.

The range of duties, procedures, and responsibilities a healthcare worker is legally and professionally permitted to perform based on licensure, training, and employer policy.

The act of assigning a task to another team member while retaining accountability for appropriate selection, instruction, and supervision of that task.

Infection-control practices applied to all patients regardless of diagnosis, including hand hygiene, gloves, and barriers when contact with blood or body fluids is likely.

Barrier garments and devices such as gloves, gowns, masks, and eye protection worn to protect the wearer from contact with infectious or hazardous materials.

A written employer program describing how occupational exposure to bloodborne pathogens is minimized, including procedures for reporting and follow-up after exposure incidents.

A puncture or cut from a needle, scalpel, or other sharp item that can transmit bloodborne pathogens and requires immediate reporting and post-exposure evaluation.

A designated area on the sterile field where sharps are placed and retrieved without hand-to-hand passing, reducing the risk of injury to team members.

A brief pause before a procedure begins in which the team verbally confirms patient identity, procedure, site, and other critical details to prevent errors.

A structured list used at defined points before, during, and after a procedure to confirm essential safety steps such as identity, antibiotics, and instrument counts.

A systematic tally of sponges, sharps, and instruments performed before, during, and at the close of a procedure to ensure no item is retained in the patient.

Any surgical item left unintentionally inside a patient after a procedure, a preventable event that can cause infection, obstruction, or serious harm.

An unexpected occurrence involving death or serious physical or psychological harm, or the risk of such harm, that triggers immediate investigation and corrective action.

A structured review method that examines underlying system factors contributing to an adverse event in order to design changes that prevent recurrence.

An ongoing, data-driven effort to measure performance, identify gaps, and test changes that improve patient outcomes and the reliability of care processes.

A measurable value tracked over time to assess whether a process or outcome meets an established standard and to guide improvement efforts.

The defined sequence of authority and communication used to escalate concerns or resolve conflicts when standard reporting lines do not address an issue.

A workplace environment in which staff feel safe and expected to voice safety concerns or questions without fear of retaliation or embarrassment.

The shared belief among team members that they can raise questions, admit mistakes, or challenge decisions without punishment or humiliation.

The obligation to accept responsibility for one's actions, decisions, and omissions, and to report errors honestly and participate in correcting them.

The principle that patients have the right to make informed decisions about their own care, including the right to refuse or withdraw consent.

The duty to protect patient health information from unauthorized access or disclosure, sharing it only with those who need it for care or legally permitted purposes.

Individually identifiable health information that is created or maintained by a covered entity and is subject to privacy and security protections under federal law.

The requirement to limit access to and disclosure of patient information to the least amount needed to accomplish the intended purpose.

A legal document in which a patient states preferences for future medical care or designates someone to make decisions if the patient loses capacity.

Objective measurements of body function, typically temperature, pulse, respiration, blood pressure, and oxygen saturation, used to detect changes in patient condition.

The initial collection of patient data at the start of care that establishes a reference point for detecting later changes in condition.

Ongoing observation and measurement of physiologic and clinical parameters during care to detect deterioration, complications, or response to intervention.

The routine cleaning of hands using soap and water or alcohol-based rub at specified moments to reduce transmission of microorganisms between patients and surfaces.

An infection occurring at or near an incision within a defined period after a procedure, often linked to contamination, technique, or patient risk factors.

The use of high-frequency electrical current to cut or coagulate tissue, requiring attention to grounding, flammable materials, and safe instrument handling.

The process of accurately identifying a tissue or fluid sample with patient identifiers, specimen type, and collection details at the point of collection.

A documented, unbroken record of who handled a specimen or item and when, used to preserve integrity for testing or legal purposes.

The practice of recording care objectively, completely, and promptly, using factual descriptions and correct patient identifiers so records reliably reflect what occurred.

A note added to a record after the time of an event, clearly marked with the actual date and time of entry and the reason it was delayed.