Dealing with risks in patient care
Quality management
Oberfeldarzt Andreas Betzholz
Qualitätsmanagementbeauftragter, Leiter ZKPLRM SG Z1
Rübenacher Straße 170
56072 Koblenz
Phone:
0261
-281-51000
Mail:
gro.rhewsednub@SQenretxEznelboKshrKZwB
querschnittlich durch alle Fachabteilungen und Funktionsbereiche incl. Technik und Verwaltung
Conference frequency: monatlich
Risk management
Andreas Betzholz
Qualitätsmanagementbeauftragter, Leiter ZKPLRM SG Z1
Rübenacher Straße 170
56072 Koblenz
Phone:
0261
-281-51000
Fax: 0261-281-50009
Mail:
gro.rhewsednub@SQenretxEznelboKshrKZwB
Steuergruppe RM im Systemverbund BwKrhser (monatlich), CIRS-Analyseteam (monatlich), RM-Kommission (halbjährlich), Verwaltung, Brandschutzbeauftragter, Sicherheitsingenieur, Infrastrukturbeauftragter, Landesbetrieb Liegenschafts- und baubetreuung, Krankenhaushygiene
Conference frequency: bei Bedarf
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QPS.FB100 Kennzahlenmatrix (28.05.2021) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management COP.VA009 Reanimation und Notfallmanagement (06.01.2023) |
| RM05 |
Pain management COP.VA004 Schmerzmanagement (04.01.2021) |
| RM06 |
Fall prophylaxis QPS.FB100 Kennzahlenmatrix (28.05.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) kontinuierliche bedarfsangepasste Aktualisierung der QM/RM-Dokumentation im Rahmen der Steuergruppe QM (02.06.2023) |
| RM08 |
Regulated handling of custodial measures PFR.VA008 Freiheitsentziehende Maßnahmen FEM (17.01.2020) |
| RM09 |
Regulated handling of occurring malfunctions of devices FMS.VA011 Einsatz von Medizinprodukten (29.04.2019) |
| 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 IPSG.CL004 Checkliste Team-Time-Out (01.04.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings ASC.CL001 Patientenvorbereitung präoperativ stationär (01.04.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups IPSG.VA004 Sicherheit bei Operationen (11.02.2021) |
| RM17 |
Standards for recovery and postoperative care ASC.CL003 Checkliste Aldrete Score (11.02.2021) |
| RM18 |
Discharge management ACC.VA003 Entlassung/Überweisung/Nachsorge (11.02.2020) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
regelmäßige CIRS-Sitzungen, Aufarbeitung von Sentinel Events, Durchführung eines Risikomanagements bei Baumaßnahmen, Steuergruppe Risikomanagement im Systemverbund Bundeswehrkrankenhäuser
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 28.04.2023 |
| IF02 |
Internal evaluation of the received reports taken bei Bedarf |
| IF03 |
Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken quartalsweise |
Conference committee
Conference frequency: monatlich
| 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) |