Dealing with risks in patient care

Quality management

Gregor Mack

Qualitätsmanagementbeauftragter

Krankenhausstr. 1
84489 Burghausen

Phone: 08671 -509-1330
Mail: ed.mukinilknnI@kcam.g

Leiter aller Bereiche und Fachabteilungen

Conference frequency: quartalsweise

Risk management

Ludwig Gutermuth

Leiter Risiko- und Prozessmanagement

Phone: 08671 -509-2777
Fax: 08671-509-1454
Mail: ed.mukinilknnI@htumretug.l

Vorstandsvorsitzender, Kaufmännischer Vorstand, Medizinvorstand Mühldorf/Haag, Medizinvorstand Altötting/Burghausen, Standortleitung/Verwaltungsleitung, Pflegedirektion, Risikomanager, QMB, verantwortlicher Leiter der zuständigen Berufsgruppe (Risikoexperte)

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

Übergeordnetes QM-Handbuch (07.07.2016)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Übergeordnetes QM-Handbuch (07.07.2016)

RM05

Pain management

Übergeordnetes QM-Handbuch (07.07.2016)

RM06

Fall prophylaxis

Übergeordnetes QM-Handbuch (07.07.2016)

RM07

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

Übergeordnetes QM-Handbuch (07.07.2016)

RM08

Regulated handling of custodial measures

Übergeordnetes QM-Handbuch (07.07.2016)

RM09

Regulated handling of occurring malfunctions of devices

Übergeordnetes QM-Handbuch (07.07.2016)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Mortalitäts- und Morbiditätskonferenzen
  • Tumorkonferenzen
  • Pathologiebesprechungen
  • 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

Übergeordnetes QM-Handbuch (07.07.2016)

RM15

Preoperative, complete presentation of necessary findings

Übergeordnetes QM-Handbuch (07.07.2016)

RM16

Procedure to avoid procedural and patient mix-ups

Übergeordnetes QM-Handbuch (07.07.2016)

RM17

Standards for recovery and postoperative care

Übergeordnetes QM-Handbuch (07.07.2016)

RM18

Discharge management

Übergeordnetes QM-Handbuch (07.07.2016)

Fault reporting systems

Conference committee

Conference frequency: wöchentlich

Measures

Medikamentensicherheit, Verbesserung Arztbriefschreibung, IT-Sicherheit, Hygienemanagement, Umsetzung MPG, Triage bei Notfallaufnahmen, Prämedikation.

No. Explanation
IF01

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

As of: 07.02.2022

IF02

Internal evaluation of the received reports

taken jährlich

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: wöchentlich

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)

EF14

CIRS Health Care