Dealing with risks in patient care
Quality management
Melanie Brüning
Leitung Qualitätsmanagement
Neuhöfer Straße 23
21107 Hamburg
Phone:
040
-181886-2269
Mail:
moc.soipelksa@gnineurb.m
Klinikleitung, Qualitätsmanagement, Pflegedirektion, Chefärzte
Conference frequency: monatlich
Risk management
Axel Wetter
Ärztlicher Direktor
21041 Hamburg
Phone:
040
-181886-2001
Fax: 040-181886-2844
Mail:
moc.soipelksa@rettew.a
Klinikleitung, Qualitätsmanagement, Pflegedirektion, Chefärzte
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Konzept Klinisches Risikomanagement (23.03.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Verfahrensanweisung (05.06.2024) |
| RM05 |
Pain management Verfahrensanweisung (22.10.2025) |
| RM06 |
Fall prophylaxis Verfahrensanweisung (27.05.2024) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Verfahrensanweisung (05.12.2024) |
| RM08 |
Regulated handling of custodial measures Verfahrensanweisung (10.10.2025) |
| RM09 |
Regulated handling of occurring malfunctions of devices Verfahrensanweisung (24.01.2023) |
| 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 Verfahrensanweisung (20.01.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings Verfahrensanweisung (20.01.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Verfahrensanweisung (15.07.2024) |
| RM17 |
Standards for recovery and postoperative care Überwachungsbogen (15.06.2023) |
| RM18 |
Discharge management Verfahrensanweisung (16.06.2023) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Sicherheitschecklisten, Austausch von risikoträchtigen Materialien, Verbesserungen Kommunikation und Prozesse
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 11.01.2023 |
| 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 |
|---|---|
|
Other |
|
| EF14 |
CIRS Health Care |