Dealing with risks in patient care

Quality management

Christel Keim

Qualitätsmanagementbeauftragte

Warburger Straße 6
34471 Volkmarsen

Phone: 05693 -680-111
Mail: ed.nesramklov-suahneknark-htebasile@miek.c

Standortübergreifende QM-Steuerungsgruppe. Teilnehmer: QMBs beider Standorte, Geschäftsführer, Pflegedirektion, Ärztlicher Direktor.

Conference frequency: quartalsweise

Risk management

Christel Keim

Qualitätsmanagementbeauftragte

Phone: 05693 -680-111
Fax: 05693-680-133
Mail: ed.nesramklov-suahneknark-htebasile@miek.c

Standortübergreifendes Risikokernteam. Teilnehmer: Risikomanager beider Standorte, Hygiene, Ärztlicher Dienst

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

Comprehensive quality and/or risk management documentation (QM/RM documentation) is available

Risikomanagement-Handbuch Qualitätsmanagement-Handbuch (19.12.2022)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Umgang mit der Notfallausrüstung, diverse Checklisten (06.09.2022)

RM06

Fall prophylaxis

Expertenstandard Sturz (04.12.2022)

RM07

Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”)

Expertenstandard Dekubitus (04.12.2022)

RM08

Regulated handling of custodial measures

Umgang mit freiheitsentziehenden Maßnahmen (17.07.2023)

RM09

Regulated handling of occurring malfunctions of devices

Medizintechnik Handbuch (11.07.2022)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Strukturiertes Besprechungswesen
RM12

Use of standardised information sheets

RM13

Application of standardised surgical check lists

RM14

Preoperative summary of predictable critical surgical steps, surgical time and expected blood loss

Periinterventionelle Identifikations- und Sicherheitscheckliste (08.08.2022)

RM15

Preoperative, complete presentation of necessary findings

Periinterventionelle Identifikations- und Sicherheitscheckliste. (08.08.2022)

RM16

Procedure to avoid procedural and patient mix-ups

Risikomanagement-Handbuch Qualitätsmanagement- Handbuch (19.12.2022)

RM17

Standards for recovery and postoperative care

Postoperative Überwachung der Patienten im Aufwachraum (11.07.2022)

RM18

Discharge management

Risikomanagement-Handbuch Qualitätsmanagement-Handbuch (19.12.2022)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Fortbildungsangebote wurden angepasst, Überarbeitung von schriftlichen Standards; Verbesserung von Organisationsprozessen, im Rahmen der Digitalisierung weitere Tools eingeführt.

No. Explanation
IF01

Documentation and procedural instructions for handling the error reporting system are available

As of: 23.03.2022

IF02

Internal evaluation of the received reports

taken monatlich

IF03

Training of employees in handling the error reporting system and in implementing the findings from the error reporting system

taken jährlich

Conference committee

Conference frequency: monatlich

No. Explanation
EF03

KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors)