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Active Error (or Active Failure)
An active error is one that is occurring at the point of care, or "sharp end", and committed by the person closest to the patient. As a result, these errors are usually easily visible, as for example, the nurse who gives the wrong dose of insulin to the patient.

In contrast, a latent error (or latent condition) may exist far away from the point of care or "sharp end". A latent error may be described as a more subtle and less evident change in the system or organization that often has a powerful effect on those at the "sharp end" of care.

An example of a latent error would be the hospital administrator who schedules the nurse to work back-to-back eight-hour shifts, greatly increasing the chance that the exhausted nurse will make an error in insulin administration.

One reason why recurrent active errors tend to be hard to prevent is that they may be largely due to latent errors which are often more powerful in their "downstream effects" but harder to spot. Until the latent error is corrected, other individuals, given the same unsafe conditions, will be prone to making errors at the "sharp end" of care.

These terms were coined by the Cognitive Psychologist, James Reason, and are widely used today.

Adverse Drug Event (ADE)
An adverse event involving medication use that may or may not be due to a medical error. An example of an adverse drug event without an error would be the first episode of muscle pain following the administration of an appropriate dose of a statin. If, on the other hand, an excessively large dose of insulin was given because of the misreading of an order, that would be an ADE due to a medication error. Many ADE’s are preventable, even if no medical error has occurred.

Adverse Drug Reaction
An adverse effect that occurs despite the correct use of a medication. An example would be orthostatic hypotension due to an antihypertensive, or a drug rash secondary to the same drug.

Adverse Event
Any injury caused by medical care. This may not be due to an error, but an expected or unexpected result of the therapy. This undesirable outcome often may be misjudged due to the presence of “hindsight bias”, but an adverse event by itself is not evidence of medical error.

Algorithm
A series of steps used to solve a problem. When an organization uses a well-validated single written algorithm for a particular problem, and the care team is taught how to correctly use the algorithm, the number of errors can be greatly reduced in delivering the care. Widespread use of common procedures and algorithms can have a positive effect on patient safety.

Algoritmo
Una serie de pasos utilizados para resolver un problema. Cuando una organización utiliza un bien único validado por escrito algoritmo para un problema particular, y el equipo de atención se ense&ntildaa c&oacoute;mo usar correctamente el algoritmo, el n&uacoute;mero de errores puede ser reducido en gran medida en la prestación de la atención. Uso generalizado de los procedimientos comunes y los algoritmos pueden tener un efecto positivo sobre la seguridad de los pacientes.

Anchoring Bias (or Error)
This is a common logical error that frequently leads to faulty analysis of a clinical setting. This cognitive error is due to the mistake of allowing a first or early impression to be overvalued in making a diagnosis.

An example of an anchoring bias is a common, but often incorrect rule of thumb, or "heuristic", such as "always trust your first impression".

Another related example is the phrase, "this and only this". When an anchoring bias leads to a knowledge based diagnostic error, physicians have a difficult time recovering from this kind of error, and find it harder to re-evaluate in light of contradictory new information. This is due to the anchoring bias.

Authority Gradient
A term used widely in crew and organizational management circles to describe the balance of decision-making power in a given situation. Another term sometimes used is the steepness of command hierarchy.

The danger of a steep authority gradient can be the understandable reluctance of members who are lower in the hierarchy to successfully challenge the even leader when there is a concern that an error was made or an unsafe condition exists. Even mere clarification of an order or situation may be difficult.

More successful "cultures of safety" make the necessary authority lines clearer, more transparent, more appropriate for the level of experience and skill, but allow the team members to question authority if there is a concern regarding an order or an analysis of the clinical needs of the patient.

Availability Bias (or Heuristic)
This bias occurs when the first explanation that comes to mind is overvalued and the process of analysis ends at that point. A common example of this bias is the well-studied example that a physician who picks up a pen with the name of a drug on it is more apt to think of that drug when writing a prescription for a drug in that class of drugs.

More serious for diagnostic problems is the tendency to choose the diagnosis already accompanying the patient chart as the cause for the present symptom set instead of exploring other options.