Dealing with risks in patient care
Quality management
M. A. Gesundheitsmanagement Heike Bördgen
Qualitätsmamangementbeauftragte
Südring 8
56428 Dernbach
Phone:
02602
-684-0
Mail:
ed.hcabnred-suahneknark@ofni
Kaufmännische Direktorin, Ärztlicher Direktor, Pflegedirektion, QMB
Conference frequency: monatlich
Risk management
Heike Bördgen
Qualitätsmamangementbeauftragte
Phone:
02602
-684-0
Fax: 02602-684-451
Mail:
ed.hcabnred-suahneknark@ofni
CIRS-Team, QM- und Risikomanagerin, Ärztlicher Direktor, Pflegedirektion, Kaufmännische Direktion, Geschäftsführung
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Elektronisches Organisationshandbuch (07.11.2024) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Verfahrensanweisung Medizinisches Notfallmanagement (03.08.2023) |
| RM05 |
Pain management Umfassende Einzelregelungen für Medizin und Pflege in SOPs und Standards (07.11.2024) |
| RM06 |
Fall prophylaxis VA Sturzprophylaxe (29.04.2024) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusprophylaxe (29.04.2024) |
| RM08 |
Regulated handling of custodial measures Verfahrensanweisung Umgang mit freiheitsentziehenden Maßnahmen (FEM) (26.06.2024) |
| RM09 |
Regulated handling of occurring malfunctions of devices Organisationshandbuch Medizinprodukte (24.10.2024) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| 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 Elektronisches Organisationshandbuch (07.11.2024) |
| RM15 |
Preoperative, complete presentation of necessary findings Elektronisches Organisationshandbuch (07.11.2024) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Verfahrensanweisung Patientenidentifikation (23.10.2024) |
| RM17 |
Standards for recovery and postoperative care Verfahrensanweisung Übergabe OP - AWR (05.06.2024) |
| RM18 |
Discharge management Elektronisches Organisationshandbuch VA Entlassmanagement (29.10.2024) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Patientenarmbänder für alle Patienten Patientensicherheitscheckliste - OP (Surgical Safety Checklist nach WHO) Team-Timeout im OP Kreissaal - Identifikationsarmband für Neugeborene Neugeborenenzimmer - videoüberwachte Zugangskontrolle Videoüberwachung im ZNA Bereich
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 21.10.2024 |
| IF02 |
Internal evaluation of the received reports taken quartalsweise |
| 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: bei Bedarf
| No. | Explanation |
|---|---|
| EF02 |
CIRS Berlin (Berlin Medical Association, German Medical Association) |