Dealing with risks in patient care
Quality management
Dr. med. Alexandra Ebert
Qualitätsmanagement
Steinerweg 5
81241 München
Phone:
089
-8892-2615
Mail:
ed.tiehdnuseg-soileh@3trebe.ardnaxela
Conference frequency:
Risk management
Reza Ghotbi
Ärztlicher Direktor
Phone:
089
-8892-2628
Fax: 089-8892-2958
Mail:
ed.tiehdnuseg-soileh@ibtohg.azer
Conference frequency:
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM und RM (zentrales Dokumentationsverzeichnis) (14.10.2024) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Verfahrensbeschreibungen im Rahmen der Rezertifizierung als regionales Traumazentrum (12.01.2022) |
| RM05 |
Pain management Handlungsempfehlung Schmerzmanagement in der Pflege bei akuten und chronischen Schmerzen - https://md-bund.de/themen/pflegequalitaet/expertenstandards-in-der-pflege.html (01.06.2022) |
| RM06 |
Fall prophylaxis Expertenstandard Sturzprophylaxe des Deutsches Netzwerk für Qualitätsentwicklung in der Pflege - https://www.dnqp.de/fileadmin/HSOS/Homepages/DNQP/Dateien/Expertenstandards/Sturzprophylaxe_in_der_Pflege/Sturz_2Akt_Auszug.pdf (01.08.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Beschluss der FG Pflege Dekubitusprophylaxe - https://www.dnqp.de/expertenstandards-und-auditinstrumente/ (01.06.2017) |
| RM08 |
Regulated handling of custodial measures Konzernregelung und Checkliste Freiheitsentziehende Maßnahmen (12.03.2024) |
| RM09 |
Regulated handling of occurring malfunctions of devices Verfahrensstandard Umgang mit Produktproblemen (01.06.2023) |
| 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 Konzernregelung OP-Sicherheit (27.01.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings Konzernregelung OP-Sicherheit (27.01.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Konzernregelung OP-Sicherheit (27.01.2022) |
| RM17 |
Standards for recovery and postoperative care Fachgruppenbeschluss zur Erhebung des Early Warning Scores bei Verlegung aus dem Aufwachraum (10.03.2023) |
| RM18 |
Discharge management VA ärztliches Entlaßmanagement (23.07.2019) |
Fault reporting systems
Conference committee
Conference frequency: halbjährlich
Measures
erfolgreiche Steigerung der Meldefrequenz, Maßnahmen zur Verbesserung der Medikamentensicherheit durch Ausbau der elektronischen Dokumentation , E-Mail-Kommunikation und Anwenderschulung
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.12.2016 |
| IF02 |
Internal evaluation of the received reports taken halbjährlich |
| 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: halbjährlich
| No. | Explanation |
|---|---|
| EF02 |
CIRS Berlin (Berlin Medical Association, German Medical Association) |
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |