Dealing with risks in patient care
Quality management
Heike Landshuter
Qualitäts- und Risikomanagement
Escherichstraße 1
91522 Ansbach
Phone:
0981
-484-0
Mail:
ed.demoigerna@kitirkdnubol
Vorstand/ Klinikdirektor:innen / Ärztliche Direktor:in / Pflegedirektor:in / MA DLZ QRM / DLZ Leitungen (Leitungskonferenz)
Conference frequency: quartalsweise
Risk management
Heike Landshuter
Qualitäts- und Risikomanagement
Phone:
0981
-484-0
Fax: 0981-484-2754
Mail:
ed.demoigerna@kitirkdnubol
Vorstand/ Klinikdirektor:innen / Ärztliche Direktor:in / Pflegedirektor:in / MA DLZ QRM / DLZ Leitungen (Leitungskonferenz)
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Handbuch Risikomanagement, VA Dokumentenlenkung (23.01.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management SOP´s (26.04.2023) |
| RM05 |
Pain management Leitbild Akutschmerztherapie, SOP Schmerz, Verfahrenanweisungen (12.07.2023) |
| RM06 |
Fall prophylaxis Expertenstandard Sturz, Übungen für Gleichgewicht und Sturzprophylaxe (28.06.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) ES Dekubitusprophylaxe in der Pflege (08.05.2023) |
| RM08 |
Regulated handling of custodial measures VA Freiheitsentziehende Maßnahmen (29.12.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices MPMT DA Medizinprodukte: Einrichten, Instandhalten, Betreiben, Anwenden; MPMT VA Regelung der Zuständigikeiten bei Medizinprodukten VS DA Strahlenschutzanweisungen Abt. (27.03.2020) |
| 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 VA OP-Statut (07.02.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings OP- Statut (07.02.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups CL Prävention von Eingriffsverwechslungen (09.01.2023) |
| RM17 |
Standards for recovery and postoperative care CL Aufwachraum (28.09.2020) |
| RM18 |
Discharge management VA Entlassmanagement (14.07.2023) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Prüfung ggf. Anpassung der SOPs; Veröffentlichung bzw. Schulung der Maßnahmen zur Verbesserung der Patientensicherheit; Regelmäßige Auswertungen; Verhaltensänderungen
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 10.07.2023 |
| 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 bei Bedarf |
Conference committee
Conference frequency: quartalsweise
| 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) |