Dealing with risks in patient care
Quality management
Dipl. Pflegew. Kathrin Auge
Koordinatorin Qualitätsmanagement
Thiemstrasse 111
03048 Cottbus
Phone:
0355
-46-2026
Mail:
ed.tc-lum@eguA.K
Qualitäts- und Risikomanagement, Vorstand, Ärztliche Direktion, Pflegedirektion, Betriebsrat
Conference frequency: halbjährlich
Risk management
Falk Steinberg
ärztliches QM / klin. RM
03003 Cottbus
Phone:
0355
-46-2275
Mail:
ed.tc-lum@grebnietS.F
Qualitäts- und Risikomanagement
Conference frequency: jährlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM Handbuch (23.04.2021) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management QM Handbuch (23.04.2021) |
| RM05 |
Pain management QM Handbuch (23.04.2021) |
| RM06 |
Fall prophylaxis QM Handbuch (23.04.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) QM Handbuch (23.04.2021) |
| RM08 |
Regulated handling of custodial measures QM Handbuch (23.04.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices QM Handbuch (23.04.2021) |
| 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 Team-Timeout-Checkliste (06.04.2020) |
| RM15 |
Preoperative, complete presentation of necessary findings Anästhesiecheckliste (22.07.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups QM Handbuch (23.04.2021) |
| RM17 |
Standards for recovery and postoperative care QM Handbuch (23.04.2021) |
| RM18 |
Discharge management QM Handbuch (23.04.2021) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Aus den Meldungen des CIRS wurden gezielt Maßnahmen zur Verbesserung der Patientensicherheit abgeleitet. Hierzu zählen die Optimierung interner Abläufe, die Förderung der Sicherheitskultur, die Verbesserung der interdisziplinären Kommunikation sowie die Initiierung von Schulungs- und Standardisierungsmaßnahmen. Dadurch konnten potenzielle Risiken frühzeitig erkannt und nachhaltige Präventionsstrategien etabliert werden.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 30.04.2024 |
| 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 bei Bedarf |
Conference committee
Conference frequency: andere Frequenz
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |