Dealing with risks in patient care

Quality management

Karin vom Holt

Qualitätsmanagementbeauftragte

Oberwolfacher Str. 10
77709 Wolfach

Phone: 0781 -472-4950
Mail: ed.mukinilk-uanetro@tnemeganamsteatilauq

3 Mitarbeitende aus dem Ärztlichen Dienst, 2 Mitarbeitende aus dem Pflegedienst, 2 Mitarbeitende aus dem Verwaltungsdienst

Conference frequency: andere Frequenz

Risk management

Karin vom Holt

Qualitätsmanagementbeauftragte

Oberwolfacher Str. 10
77709 Wolfach

Phone: 0781 -472-4950
Fax: 0781-472-4902
Mail: ed.mukinilk-uanetro@tnemeganamsteatilauq

Ärztlicher Vorstand, Pflegerische Vorständin, Mitarbeitende des Risikomanagements

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

Leitlinie Risikopolitik, Konzept Risikomanagement (24.06.2022)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Alarmierung und Zuständigkeiten in Notfall- und Reanimationssituationen (18.04.2018)

RM05

Pain management

Leitfaden zur Schmerztherapie / Tumorschmerztherapie (01.09.2022)

RM06

Fall prophylaxis

Standard "Sturzprophylaxe (20.04.2021)

RM07

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

Standard "Dekubitusprophylaxe" (20.04.2021)

RM08

Regulated handling of custodial measures

ZEN VA Zwangsmaßnahmen (30.07.2021)

RM09

Regulated handling of occurring malfunctions of devices

Dienstanweisung für den Betrieb von aktiven, nicht implantierbaren Medizinprodukten (12.02.2023)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • einmal monatlich interdisziplinäre Fortbildung und Fallbesprechung
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 Perioperative Sicherheits-Checkliste (06.04.2021)

RM16

Procedure to avoid procedural and patient mix-ups

OP Perioperative Sicherheits-Checkliste (06.04.2021)

RM17

Standards for recovery and postoperative care

Verlegungskriterien Aufwachraum (02.01.2023)

RM18

Discharge management

Prozess "Entlassmanagement" (15.09.2019)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Ein Hinlauftendenz-Sicherheitssystem wurde beschafft.

No. Explanation
IF01

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

As of: 07.07.2022

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: andere Frequenz

No. Explanation

Other

EF03

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