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A short course of lectures
«Safer Healthcare»





The Changing Nature of HealthcareThe Enthusiasm of the Early Years, 1995–2002Reflections on Home Care SafetyKey PointsThree Approaches to the Management of RiskAdopting a Range of Safety ModelsReflections on Safety in Primary CareThe Cumulative Impact of Poor Quality CareSupport Systems for Staff and PatientsThe Resources of the Patient and Family Are Critical to Safe CareMonitoring, Adaptation and ResponseThe Benefits and Risks of Information TechnologyThe Challenges and Risks of Care CoordinationApproaches to Safety: One Size Does Not Fit AllTeam Training in Monitoring, Adapting and ResponseSafety and Quality of Care from the Patient's PerspectiveKey PointsThe Consequences for Incident Analysis Improving the SystemThe Burden of Healthcare: Impact on Patients and CarersRisk Control StrategiesStrategy I: Safety as Best PracticeConsidering Benefit and Harm Along the Patient JourneyImproving the SystemA Global Revolution Rather Than a Local EvolutionSafety Culture, Multifaceted Interventions, and Teamwork 2005–2011Explicit Discussion of the Real Standard of Care Is CriticalReliability of Clinical Systems in the British NHSKey PointsReducing the Burden on Staff: Simplification and DeclutteringComparing Actual Care with the Care Intended by GuidelinesControl of HazardsWhat Are We Trying to Learn When We Analyse Incidents?What Do We Mean by Harm?Levels of Care and Strategies for Safety ImprovementInfluences on Safety of Healthcare Delivered in the HomeOptimization Strategies in Home Care: Best Practice and System ImprovementThe Responsibilities of CarersThe Hazards of Home Care: New Risks, New ChallengesKey PointsFollowing the Rules: Reliability of Human BehaviourOur Model of Intervention Is LimitedPatient Safety as the Management of Risk Over TimeControl of MedicationManaging Risk: The High Reliability ApproachRules and AdaptationThe Benefits and Risks of ScreeningFragmented Approach of Healthcare ProfessionalsMonitoring, Adaptation and ResponseCoordination of Care Is a Major Safety IssueWiden the Time Frame of Analysis: Review the Patient JourneyA Compendium of Safety Strategies and InterventionsInnovationDetecting DeteriorationThe Home Environment as Risk FactorRethinking Patient SafetyPotential for 'Go and No-Go' Controls in SurgeryProgress on Patient SafetySelection and Customisation of Strategies to Clinical ContextSafety Strategies for Care in the HomeWhat Options Do We Have for Improving Safety?Embracing Risk: The Ultra-adaptive ModelPlacing Limits on CareBriefings and Debriefings, Handovers and Ward RoundsMitigation Strategies in Home HaemodialysisMitigationReflections on the Safety IdealIncreasing Responsibilities of CarersFive Safety StrategiesNew Challenges for Patient SafetySeeing Safety Through the Patient's EyesImproving Transitions Between Hospital and Primary CareA Compendium of Safety StrategiesAvoiding Risk: The Ultra-safe ApproachKey PointsKey PointsImplications for Executives and BoardsApproaches to Risk and Hazard: Embrace, Manage or AvoidReflections on Safety in HospitalsOnly Part of the Healthcare System Has Been AddressedDiagnostic ErrorsFuture Directions for Research and PracticeSafety Is a Moving TargetKey PointsWe Are Approaching Safety in the Same Way in All SettingsThe Challenges of Delivering Healthcare in the HomeStrategy III: Risk ControlSeeing Safety Through the Patient's Eyes The Ideal and the Real: Five Levels of CareSafety Strategies in HospitalsSuccess and Failure in Detection and RecoveryNew Challenges for Patient SafetyRisk Control Strategies in Home CareThe Day-to-Day Realities of HealthcareProgress and Challenges for Patient SafetyThe Training and Experience of Home Care AidesSafety in Hospital: Distinguishing Current and Future StrategiesPatients and Families as Problem DetectorsRisk ControlSafety Strategies and Interventions in the HomeControl by Assessment of CompetencyProblems of Transition and CoordinationHow Many Models for Healthcare?The Nature of Risk in Primary CareStrategy V: MitigationKey PointsKey PointsRegulatory and Political Determinants of Approaches to SafetyThe Advent of Professionalism 2002–2005Strategies for SafetyHarm Has Been Defined Too NarrowlySafety as Best PracticeThe Patient Potentially Has the Most Complete PictureEssential Concepts of ALARMEKey PointsMitigationStrategy IV: Monitoring, Adaptation and ResponseSafety Strategies in Primary Care Box 8.1. Difficult Challenge for Optimisation Strategies: Lessons from a Centralised Nurse-led Cholesterol-Lowering ProgrammeImproved Safety in Some ContextsHealthcare Is ChangingDeveloping a Wider Range of Safety StrategiesSelect Problems for Analysis Which Are Important to PatientsTraining of Patients and CarersStrategy II: Improvement of Work Processes and SystemsMoving Between ModelsThe Ideal and the Real Accidental Injury in the HomeAdverse Drug EventsMonitoring, Adaptation and Response Strategies in Home CareSocio-economic Conditions Take on a Much Greater ImportanceImplications for Regulatory Agencies and GovernmentAdapting the Analysis to ContextBox 2.1 Observation of Patients at Risk of Suicide: When Working Conditions Make It Difficult to Follow ProceduresError and Harm in Primary CareMitigationSafety in Context: The Many Hospital EnvironmentsImplications for Frontline Clinicians and ManagersManaging Risk in the Real World The Healthcare professional's View Is Necessarily IncompleteWhat Is the Impact of Improving Quality Standards?Adverse Events in Home CareAn Ageing Population and the Expansion of Home CareRisk to Family and Other Care GiversImplications for Patients, Carers and FamiliesChallenges for Primary CareDeveloping a More Systematic Approach to Watching and WaitingDischarge Planning and the Journey from Hospital to HomeIncreasing ComplexitySafety as Best PracticeA Little HistorySafety Through the Patient's EyesKey Points
 
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