Dealing with risks in patient care

Quality management

Dipl. Kff. Jessica Günther

Leiterin Qualitätsmanagement

Richardstraße 5-9
66333 Völklingen

Phone: 06898 -12-2583
Mail: ed.nekinilk-ghs.kv@rehtneug.j

Steuerkreissitzung, Teilnehmer: Verwaltungsdirektor, Pflegedirektorin, ärztlicher Direktor, plus jeweilige Stellvertreter, Leiterin Qualitätsmanagement, Betriebsratsvorsitzende + Stellvertreter, Leiter Personal- und Organisationsentwicklung

Conference frequency: monatlich

Risk management

Jessica Günther

Leiterin Qualitätsmanagement

Phone: 06898 -12-2583
Fax: 06898-12-2409
Mail: ed.nekinilk-ghs.kv@rehtneug.j

Interdisziplinär (je Fachabteilung ein Arzt und eine Pflegekraft) besetztes CIRS Auswertungsteam

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

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

Integriertes Risikomanagement (01.05.2020)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Notfallmanagement Konzept (01.05.2020)

RM05

Pain management

Integriertes Risikomanagement (01.05.2020)

RM06

Fall prophylaxis

Integriertes Risikomanagement (01.05.2020)

RM07

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

Integriertes Risikomanagement (01.05.2020)

RM08

Regulated handling of custodial measures

Integriertes Risikomanagement (01.05.2020)

RM09

Regulated handling of occurring malfunctions of devices

Integriertes Risikomanagement (01.05.2020)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Palliativbesprechungen
  • Qualitätszirkel
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

Integriertes Risikomanagement (01.05.2020)

RM15

Preoperative, complete presentation of necessary findings

Integriertes Risikomanagement (01.05.2020)

RM16

Procedure to avoid procedural and patient mix-ups

Integriertes Risikomanagement (01.05.2020)

RM17

Standards for recovery and postoperative care

Integriertes Risikomanagement (01.05.2020)

RM18

Discharge management

Integriertes Risikomanagement (01.05.2020)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Patientensicherheitsschirm

No. Explanation
IF01

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

As of: 01.06.2021

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
EF01

CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association, National Association of Statutory Health Insurance Doctors)

EF02

CIRS Berlin (Medical Association Berlin, German Medical Association, National Association of Statutory Health Insurance Doctors)

EF03

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