Dealing with risks in patient care
Quality management
Marcel Heneck
Direktor Prozesse und Qualitätsmanagement
Am Steinbühl 2
35781 Weilburg
Phone:
06471
-313-297
Mail:
ed.grubliew-suahneknark@kceneh.lecram
Conference frequency:
Risk management
Marcel Heneck
Direktor Prozesse und Qualitätsmanagement
Am Steinbühl 2
35781 Weilburg
Phone:
06471
-313-297
Fax: 06471-313-221
Mail:
ed.grubliew-suahneknark@kceneh.lecram
Direktor Prozesse und QM, QM-Beauftragte, Risikomanagerin, Pflegedirektor, Ärztlicher Direktor, Mitgleider des CIRS-Auswerterteams
Conference frequency: jährlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available DOC_0055 Richtlinie zum Risikomanagement (01.11.2021) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management VA_0094 Notfallmanagement (25.04.2018) |
| RM05 |
Pain management KO_0009 Konzept zur perioperativen Schmerztherapie; KO_0020 Schmerzkonzept Chirurgie; KO_0025 Schmerzkonzept Orthopädie/ Unfallchirurgie (27.04.2023) |
| RM06 |
Fall prophylaxis VA_0157 Standard zur Sturzprophylaxe (28.06.2018) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) VA_0084 Verfahren zur Dekubitusprophylaxe (10.10.2017) |
| RM09 |
Regulated handling of occurring malfunctions of devices DOC_0026 Handbuch Einsatz Medizinprodukte; VA_0080 Sicherstellung gesetzliche Prüfungen nach MPG (19.07.2017) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM13 |
Application of standardised surgical check lists |
| RM16 |
Procedure to avoid procedural and patient mix-ups VA_0197 Anwendung Patientenidentifikationsarmband; VA_0130 OP Statut; VA_0461 OP-Management (15.02.2022) |
| RM17 |
Standards for recovery and postoperative care VA_0169 Schmerzmessung und postop. Routineüberwachung, A_0015 Therapiealgorithmus postop. Infektionen (27.04.2023) |
| RM18 |
Discharge management VA_0179 Entlassungsmanagement (18.03.2015) |
Fault reporting systems
Conference committee
Conference frequency: jährlich
Measures
CIRS (intern); Anwendung von Patientenidentifikationsarmbändern; MRSA Screening bei allen Patienten; Anwendung WHO-Checkliste im OP; Team-Time-out; Einarbeitungskonzepte für alle Berufsgruppen; HACCP; Thrombose-, Sturz- und Dekubitusprophylaxe, regelmäßige Sensibilisierung der Mitarbeiter zum Thema Patientenidentifikation und -sicherheit
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.01.2023 |
| IF02 |
Internal evaluation of the received reports taken jährlich |
| 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: bei Bedarf
| No. | Explanation |
|---|---|
| EF01 |
CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association, National Association of Statutory Health Insurance Doctors) |