Dealing with risks in patient care

Quality management

Maya Brand

Qualitätsmanagementbeauftragte

Am Dreilingsberg 7
23570 Lübeck-Travemünde

Phone: 0451 -585-1861
Mail: ed.anas@dnarb.ayam

Geschäftsführung, Pflegedirektor, Personal und Organisation, Ärztlicher Direktor, Klinikmanager, Kaufmännische Leitung

Conference frequency: monatlich

Risk management

Maya Brand

Qualitätsmanagementbeauftragte

Am Dreilingsberg 7
23570 Lübeck-Travemünde

Phone: 0451 -585-1861
Mail: ed.anas@dnarb.ayam

Geschäftsführung, Pflegedirektor, Personal und Organisation, Ärztlicher Direktor, Klinikmanager, Kaufmännische Leitung

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

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

Regelhafte externe Risikoaudits (23.09.2021)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Interner Notfallalgorithmus (31.05.2021)

RM05

Pain management

Perioperative Schmerztherapie (01.11.2018)

RM06

Fall prophylaxis

Sturzprophylaxe bei erwachsenen Patienten (25.08.2020)

RM07

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

Standard Dekubitusprophylaxe (08.08.2017)

RM08

Regulated handling of custodial measures

Freiheitsentziehende Maßnahmen (03.09.2019)

RM09

Regulated handling of occurring malfunctions of devices

Lenkung fehlerhafter Produkte (09.11.2020)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Palliativbesprechungen
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

WHO-OP-Checkliste (15.12.2017)

RM15

Preoperative, complete presentation of necessary findings

WHO-OP-Checkliste (15.12.2017)

RM16

Procedure to avoid procedural and patient mix-ups

Patientenidentifikation (08.12.2021)

RM17

Standards for recovery and postoperative care

Überwachung von Patienten im Aufwachraum (11.01.2018)

RM18

Discharge management

Entlassmanagement (18.05.2020)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Umgesetzte Maßnahmen werden jährlich in einem Managementgespräch nach DIN EN ISO 9001:2015 Norm bewertet.

No. Explanation
IF01

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

As of: 18.05.2018

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: