DHA Specialist Exam key terms

A patient's voluntary agreement to a procedure or treatment after receiving and understanding information about its purpose, risks, benefits, and alternatives, given without coercion and by someone with decision-making capacity.

A clinician's bedside judgment that a patient can understand relevant information, appreciate the consequences of choices, reason through options, and communicate a consistent decision about their own care.

A patient's informed and voluntary decision to decline a recommended test or treatment after being told the risks of declining and reasonable alternatives, documented in the record.

A person legally authorized to make health care decisions for a patient who lacks capacity, chosen in advance by the patient or appointed by a court or statute.

A written statement made while a patient has capacity that records future treatment preferences or names a substitute decision-maker, used to guide care if the patient later loses capacity.

A documented medical order, agreed with the patient or their proxy, that CPR should not be started if the patient has a cardiac arrest, while other appropriate care continues.

A structured conversation with the patient or family that clarifies what matters most to them and aligns treatment plans with those priorities, especially in serious or advanced illness.

The professional duty to keep patient information private and share it only with those involved in care or when legally or ethically justified, such as with consent or to prevent serious harm.

Any unauthorized disclosure of patient information, whether accidental or deliberate, that violates privacy obligations and may require disclosure to the patient and corrective action.

The principle that only the least amount of patient information needed for a specific purpose should be accessed, used, or shared, limiting exposure to sensitive data.

Individually identifiable health information held or transmitted by a covered entity, including data in any form, that is subject to privacy and security rules.

The measured rate at which staff perform appropriate hand cleaning at required moments, a core infection prevention behavior audited and improved through feedback and education.

Routine infection control practices applied to all patients, including hand hygiene, gloves, gowns, and safe handling of sharps and body fluids, regardless of known infection status.

Barriers such as gloves, gowns, masks, and eye protection worn to prevent contact with infectious agents or hazardous materials during patient care.

Extra precautions beyond standard practice, such as contact, droplet, or airborne measures, used for patients with known or suspected pathogens spread by those routes.

An infection a patient acquires during or shortly after receiving care that was not present or incubating at admission, often linked to devices, procedures, or lapses in infection control.

A confidential internal record of an adverse event, near miss, or unsafe condition used for quality improvement and risk management, not for assigning blame to individuals.

An unintended injury or harm to a patient caused by medical management rather than the underlying disease, which may or may not be preventable.

An event that could have caused harm but did not reach the patient, or was caught before causing injury, and is reported to reveal system weaknesses.

A structured team investigation after a serious adverse event that traces contributing system factors and produces recommendations to prevent recurrence.

A small-scale, iterative quality improvement method in which a change is planned, tested, studied for results, and then adapted or adopted before wider rollout.

A systematic comparison of current practice against agreed standards, followed by targeted changes and re-measurement to confirm improvement in care quality.

A measurable metric chosen to track whether a process or outcome meets a quality target, used to monitor performance over time and guide improvement efforts.

Comparing an organization's or clinician's performance metrics against internal targets or peer standards to identify gaps and prioritize improvement.

The required process of confirming a patient's identity using at least two independent identifiers before giving care, medication, or procedures, to prevent wrong-patient errors.

A brief pause by the procedural team before starting an invasive procedure to confirm the correct patient, site, procedure, and availability of needed equipment and consent.

A standardized list used at three phases of an operation to verify safety steps such as identity, allergies, antibiotic timing, instrument counts, and specimen labeling.

A formal process of comparing a patient's current medication list with new orders at transitions of care to identify and resolve discrepancies and prevent errors.

A drug that carries a heightened risk of significant harm when used incorrectly, requiring extra safeguards such as independent double-checks, clear labeling, and limited access.

Different drugs with similar names or packaging that are easily confused, managed through tall-man lettering, separate storage, and read-back verification of orders.

A communication technique in which the sender gives a clear message, the receiver repeats it back, and the sender confirms accuracy, reducing misunderstandings in high-stakes settings.

A structured way to transfer patient information using Situation, Background, Assessment, and Recommendation, improving completeness and safety during shift changes or referrals.

A workplace environment where any team member feels safe and expected to raise safety concerns or question unsafe orders without fear of retaliation.

An approach to error management that distinguishes honest mistakes from reckless behavior, encouraging reporting while still holding people accountable for unsafe choices.

A discharge that occurs when a patient with capacity chooses to leave despite advice to stay, documented with risks explained, alternatives offered, and follow-up arranged.

A prioritized list of possible conditions that could explain a patient's presentation, refined by history, examination, and testing to guide safe next steps.

The cognitive process of gathering and interpreting data, forming and testing hypotheses, and deciding on actions while monitoring for errors and changing information.

A symptom, sign, or test result that signals serious underlying disease or urgent risk and prompts immediate escalation or investigation rather than routine management.

The estimated likelihood that a patient has a condition before a test is done, used to interpret results and decide whether testing will meaningfully change management.

Test characteristics describing the ability to correctly identify people with a condition (sensitivity) and those without it (specificity), shaping interpretation of results.

The probability that a person with a positive test result truly has the condition, which rises as disease prevalence in the tested population increases.

Ordering the right tests for the right reasons at the right time, avoiding unnecessary or low-value testing that can cause harm, false positives, and wasted resources.

Timely referral of a deteriorating patient to a more senior clinician or rapid response team using agreed triggers and structured communication.

A numeric score calculated from routine vital signs that flags clinical deterioration and triggers a defined response when it crosses set thresholds.

A structured document given at hospital discharge that records diagnoses, treatments, medication changes, follow-up plans, and information needed for continuity of care.

A standardized, evidence-based plan outlining the expected steps, roles, and timing of care for a defined condition or procedure across the patient journey.

Formal external recognition that a healthcare organization meets published standards for safety and quality, usually reviewed periodically through survey and evidence of compliance.

The range of roles, tasks, and decisions a clinician is permitted and competent to perform under their license, training, and employer policy.

Assigning a task to another team member while retaining accountability for the overall care, ensuring the person has the competence and authority to perform it.

The limit between a clinician's professional role and personal relationship with a patient that protects trust, avoids exploitation, and guides appropriate conduct.

A situation where personal, financial, or other interests could improperly influence professional judgment, requiring disclosure and management to protect patient trust.

A patient's ability to obtain, understand, and use health information to make decisions, which clinicians support through plain language and teach-back.

A communication check in which the patient explains information back in their own words, letting the clinician confirm understanding and correct misunderstandings.

A collaborative process where clinician and patient discuss options, evidence, and patient values together to reach an agreed care decision.

A confidential mechanism through which staff log adverse events, near misses, and hazards so that patterns can be analyzed and systems improved.