CPPS key terms

A fair-accountability framework that distinguishes human error, at-risk behavior, and reckless behavior, responding with consolation, coaching, or sanction respectively. It encourages reporting by protecting staff who disclose mistakes honestly.

A shared belief among team members that speaking up with questions, concerns, or errors will not bring humiliation or punishment. It is a precondition for learning, error reporting, and effective team communication.

An environment where any team member, regardless of rank, feels able and expected to voice safety concerns in real time. It depends on leadership responsiveness and clear, nonpunitive escalation pathways.

A healthcare worker who is traumatized or distressed after being involved in an unanticipated patient harm event. Supporting second victims reduces turnover and preserves reporting and safety engagement.

Perceived differences in authority or status that discourage lower-ranking team members from challenging decisions or raising concerns. Flattening these gradients through structured communication improves safety.

Scheduled visits by senior leaders to clinical areas to ask frontline staff about safety concerns and demonstrate visible commitment. Concerns are logged, followed up, and reported back to staff.

The visible, consistent allocation of attention, resources, and authority by leaders to safety priorities. It is a strong predictor of staff safety perceptions and is measured in culture surveys.

A governing-body committee that oversees safety and quality performance, reviews harm data, and holds executives accountable. It links clinical improvement work to organizational strategy and resource decisions.

The obligation of individuals and teams to own their responsibilities, report results transparently, and act on agreed improvements. In safety work it is paired with support and fair evaluation rather than blame.

A brief, structured team meeting, often at shift start, to review current risks, recent events, and planned actions. It builds situational awareness and rapid escalation of emerging concerns.

An injury or harm to a patient caused by medical management rather than the underlying condition. Adverse events may be preventable or nonpreventable and are a core target of safety measurement.

An unexpected occurrence involving death, serious physical or psychological injury, or the risk thereof, that signals the need for immediate investigation and response. Examples include wrong-site surgery and retained foreign objects.

An event that could have caused harm but did not, either by chance or because it was intercepted. Near misses are high-value learning opportunities and should be reported and analyzed.

Patient injury arising from care delivery that could reasonably have been avoided through systems, process, or behavior changes. It is the primary outcome targeted by patient safety improvement efforts.

A ranking of risk controls from strongest (elimination, substitution, engineering controls) to weakest (warnings, training, personal protective equipment). It guides selection of durable, system-level safeguards.

A design feature that makes an incorrect action difficult or impossible, such as connectors that fit only one port. It is a strong engineering control that reduces reliance on human vigilance.

The study of how human capabilities and limitations interact with tools, tasks, and environments. Applying it improves usability, reduces error, and supports safer workflows and equipment design.

The transfer of patient information and responsibility between care providers or teams. Structured handoffs reduce omissions, misunderstandings, and gaps in care during transitions.

A structured communication format covering Situation, Background, Assessment, and Recommendation. It standardizes information transfer, especially in urgent escalation and handoff situations.

A validated questionnaire that measures staff perceptions of safety climate, teamwork, reporting, and leadership. Results are compared over time and to benchmarks to target culture interventions.

The measurable, shared perceptions of safety policies, practices, and behaviors at a point in time. It is more surface-level and changeable than culture and is often assessed by survey.

A retrospective chart-review method that uses defined triggers (such as antidote administration or abnormal lab values) to identify adverse events and estimate harm rates over time.

A confidential mechanism for staff to report errors, near misses, and hazards. Its value depends on ease of use, nonpunitive response, and feedback that closes the loop with reporters.

A performance framework that tracks measures across financial, customer, internal process, and learning perspectives. In healthcare it aligns safety and quality goals with organizational strategy.

A quantifiable measure chosen to track progress toward a specific safety or quality objective. Good indicators are actionable, attributable to the team, and reviewed on a defined cadence.

A method using control charts to distinguish common-cause variation from special-cause variation in a process over time. It supports data-driven decisions about when to act.

A time-ordered plot of data with a median line, used to detect signals of change such as shifts or trends. It is simple to construct and useful for rapid improvement monitoring.

A structured improvement method with four steps: Plan, Do, Study, Act. Small rapid cycles test changes, generate learning, and inform whether to adapt, adopt, or abandon an intervention.

An improvement framework built around three questions (aim, measures, changes) and tested through PDSA cycles. It provides a disciplined structure for linking goals to measurable change.

A structured retrospective method to identify contributing factors and system failures behind an adverse event. Its goal is redesign to prevent recurrence, not individual blame.

A proactive team method that maps a process, identifies where it could fail, and scores failure modes by severity, occurrence, and detectability. It prioritizes redesign before harm occurs.

A technique that aggregates multiple reported events to find shared contributing factors across cases. It complements single-event analysis by revealing recurring system weaknesses.

Reducing unnecessary variation in supplies, processes, and protocols so that expected steps are predictable. It reduces error, supports training, and makes outcomes easier to measure.

A practice of going to the place where work actually happens to observe processes and ask questions directly. It grounds improvement in real workflows rather than assumptions.

A team-training framework emphasizing communication, leadership, situation monitoring, and mutual support. Tools such as briefs, huddles, and debriefs build teamwork and reduce safety events.

Learning activities in which members of different health professions learn with, from, and about each other. It strengthens collaboration, role clarity, and shared safety competencies.

A syndrome of emotional exhaustion, depersonalization, and reduced efficacy resulting from chronic workplace stress. It is associated with more errors, lower safety climate, and staff turnover.

Involving patients and families as partners in care design, decision-making, and safety efforts. Engagement improves error detection, adherence, and the relevance of improvement priorities.