MNMC Nursing key terms

The legally defined set of activities a nurse may perform, set by state law and board rules, based on license level and training rather than employer preference or personal comfort.

The state statute that creates the board of nursing, defines licensure, and establishes the legal boundaries of nursing practice within that jurisdiction.

The degree of care and skill a reasonably prudent nurse with similar training would provide in similar circumstances; used to judge whether negligence occurred.

Failure to meet the standard of care, causing harm; requires duty, breach, causation, and damages to be established before liability attaches.

Professional negligence by a nurse or other clinician in the course of practice; a civil claim decided on the same four elements as ordinary negligence.

A patient's voluntary agreement to a procedure after receiving and understanding its purpose, risks, benefits, and alternatives; the provider obtains it, the nurse verifies and witnesses.

A written statement made while a patient has capacity, naming a surrogate decision-maker or specifying desired treatment, that guides care when the patient can no longer speak.

The legal and ethical duty to protect patient health information from unauthorized disclosure, including casual conversation, social media, and unsecured messaging.

The federal law governing privacy and security of protected health information, permitting disclosure only for treatment, payment, operations, or as otherwise authorized or required.

A legal obligation to notify authorities of specified events such as suspected abuse, certain communicable diseases, or impaired practice, even without patient permission.

Entitlements including respect, privacy, information, refusal of treatment, and freedom from restraint, protected by federal conditions of participation and state law.

Actively protecting and promoting a patient's interests, preferences, and safety, including speaking up when care, staffing, or decisions threaten them.

The defined sequence of authority a nurse follows to escalate a concern, from charge nurse to manager, supervisor, and administrator, used when immediate risk exists.

A workplace norm in which staff at any level feel safe raising safety concerns without fear of retaliation, supported by leadership and nonpunitive response to error.

A framework that distinguishes human error, at-risk behavior, and reckless conduct, responding with support, coaching, or sanction respectively rather than blaming all outcomes equally.

A structured team review after a serious safety event that traces contributing system factors and produces corrective actions, distinct from individual performance discipline.

An unexpected occurrence involving death or serious physical or psychological harm, or the risk of it; triggers immediate investigation and notification under accreditation standards.

An internal record of an adverse event or near miss used for quality improvement and risk analysis; it is not placed in the medical record and does not replace charting.

A proactive team method that maps a process step by step, predicts where it could fail and how harmful that failure would be, and redesigns before harm occurs.

A rapid-cycle improvement method: plan a small change, carry it out, study the measured result, and act by adopting, adapting, or abandoning it before the next cycle.

A measurable marker of care structure, process, or outcome, such as fall rate or catheter-associated infection, used to compare performance and target improvement.

Comparing a unit's or hospital's performance measure against internal targets, peer institutions, or national databases to identify gaps and prioritize improvement work.

A serious, largely preventable adverse occurrence such as wrong-site surgery, retained foreign object, or transfusion reaction from error, which is reportable and expected to be zero.

A brief pause immediately before a procedure in which the team verbally confirms patient identity, site, procedure, and consent, all agreeing before starting.

The requirement to verify identity using two independent data elements, such as full name and date of birth, never the room number or bed, before any care or medication.

A drug carrying heightened risk of substantial harm when used in error, such as insulin, heparin, opioids, and concentrated electrolytes, requiring independent double checks and standardized storage.

Two clinicians separately verify a calculation, dose, pump setting, or product without seeing each other's work, so one error is unlikely to be confirmed by the other.

Medication name pairs that look or sound similar, such as hydrOXYzine and hydrALAZINE, which require tall-man lettering, separated storage, and read-back verification.

Core checks before giving a drug: right patient, drug, dose, route, time, reason, and documentation, plus the patient's right to refuse and to be educated.

A formal process of building and comparing a complete medication list at admission, transfer, and discharge to identify omissions, duplications, and interactions.

The relationship between a drug's toxic and effective doses; a narrow index means small dose changes or missed doses can produce toxicity or loss of effect.

Measuring serum drug levels, often with peak or trough timing, for drugs with narrow therapeutic ranges such as vancomycin, digoxin, and lithium, to individualize dosing.

A harmful, unintended response to a medication at a normal dose; documented, reported, and distinguished from an allergic reaction or a medication error.

Transferring performance of a specific task to a competent assistive person while the nurse retains accountability for assessment, judgment, supervision, and outcome evaluation.

Right task, right circumstance, right person, right direction and communication, and right supervision and evaluation; all five must be satisfied before handing off a task.

A trained worker without a nursing license who performs delegated, routine tasks such as hygiene and vital signs under nurse direction, and who cannot assess or teach.

A structured handoff format: situation, background, assessment, and recommendation, used to communicate a patient's condition concisely and prompt a clear response.

The transfer of patient information and accountability between caregivers or units, ideally standardized, interactive, and including opportunity for questions and read-back.

A technique in which the receiver repeats an instruction back to the sender and the sender confirms accuracy, preventing misheard orders during urgent or noisy situations.

Verbal repetition of a telephone or verbal order or critical result by the receiver to the prescriber, who confirms it, followed by documentation of the exchange.

Movement of a patient between settings or providers, such as hospital to home or to a skilled facility, requiring reconciled medications, written instructions, and follow-up plans.

Education before leaving a setting covering medications, warning signs, activity, diet, equipment use, and whom to call, confirmed by teach-back and delivered in plain language.

Asking the patient to explain in their own words how they will take a medicine or what warning sign means, revealing misunderstanding without shaming them.

A person's ability to obtain, understand, and act on health information; limited literacy is common and is addressed with plain language, pictures, and teach-back.

Writing and speaking that uses short familiar words, active voice, and short sentences, avoiding jargon so the message is understood on first reading or hearing.

A collaborative conversation style that draws out a patient's own reasons for change using open questions, reflective listening, and affirmation rather than advice-giving.

A model describing readiness to alter behavior across precontemplation, contemplation, preparation, action, and maintenance, guiding interventions matched to the current stage.

Activities that help people increase control over and improve their health, including screening, immunization, counseling, and environment change, beyond treating existing illness.

A targeted evaluation of one body system or complaint, gathering only the data needed to judge the current problem and act, used in urgent or follow-up situations.

A systematic full-body examination performed on admission and when condition changes, establishing a baseline against which later findings are compared.

The observed outcome of critical thinking in practice: noticing relevant cues, interpreting them, responding with action, and evaluating whether the response worked.

A numeric score calculated from routine vital signs that flags deterioration risk and triggers a defined escalation response when it crosses a threshold.

The initial set of findings collected at first contact, used to detect meaningful change later; without it, subtle deterioration or improvement can be missed.

A standardized screen of factors such as mobility, medications, cognition, and continence that determines which fall-prevention bundle a patient receives.

Classification of localized skin and tissue damage by depth and tissue type, from nonblanchable redness through full-thickness loss, which directs prevention and treatment.

A scored tool rating sensory perception, moisture, activity, mobility, nutrition, and friction to predict pressure injury risk and prompt preventive interventions.

The contemporaneous, factual, objective record of assessment, interventions, and response that supports continuity of care and serves as legal evidence of practice.