Dealing with risks in patient care

Quality management

Frau Tina Rohrbach

Qualitätsmanagementbeauftragte

Mühlhäuser Straße 94-95
99817 Eisenach

Phone: 03691 -698-1130
Mail: ed.mukinilkgroegts@aniT.hcabrhoR

z.B. Qualitätszirkel , CIRS-Team, Krankenhausbetriebsleitung, Chefarztkonferenz, Stationsleitungsbesprechungen, Tumorkonferenzen

Conference frequency: monatlich

Risk management

Tina Rohrbach

Qualitätsmanagementbeauftragte


99817 Eisenach

Phone: 03691 -698-1130
Mail: ed.mukinilkgroegts@aniT.hcabrhoR

CIRS Team

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

Prozessbeschreibung CIRS Eingabe und Auswertung (09.02.2023)

RM02

Regular further education and training measures

RM04

Clinical emergency management

Notfallkonzept (21.06.2023)

RM05

Pain management

Pflegerisches Schmerzmanagement (01.02.2023)

RM06

Fall prophylaxis

Expertenstandard Sturzprophylaxe (09.12.2022)

RM07

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

Expertenstandard Dekubitusprophylaxe (09.12.2022)

RM08

Regulated handling of custodial measures

Umgang mit Fixierungen (28.02.2022)

RM09

Regulated handling of occurring malfunctions of devices

Umgang mit Medizinprodukten (27.04.2021)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • 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

OP-Sicherheitscheckliste (17.07.2023)

RM15

Preoperative, complete presentation of necessary findings

OP-Sicherheitscheckliste (17.07.2023)

RM16

Procedure to avoid procedural and patient mix-ups

OP-Sicherheitscheckliste (17.07.2023)

RM17

Standards for recovery and postoperative care

Postoperative Betreuung und Überwachung eines Patienten im AWR (27.04.2021)

RM18

Discharge management

Expertenstandard Entlassmanagement (17.04.2023)

Fault reporting systems

Conference committee

Conference frequency: quartalsweise

Measures

Patientenidentifikationsarmband, OP-Checklisten

No. Explanation
IF01

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

As of: 09.02.2023

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)