Dealing with risks in patient care

Quality management

Claudia Mohm

Qualitätsbeauftragte

Graf-Siegfried-Str. 115
54439 Saarburg

Phone: 06581 -82-1150
Mail: ed.grubraas-hk@mhom.c

Risikomanagement Fr. Irene Schuster - Pflegedirektorin, Projektmanagement - Hr. F. Bergmann - stellv. Pflegedirektor; Qualitätsmanagement - Fr Mohm - Laborleitung, Hr. P. Schmusch (LKH), Hr. T. Weber

Conference frequency: monatlich

Risk management

Irene Schuster

Risikomanagement

Graf-Siegfried-Str. 115
54439 Saarburg

Phone: 06581 -82-1301
Fax: 06581-82-1703
Mail: ed.grubraas-hk@retsuhcs.i

Risikomanagement Fr. Irene Schuster - Pflegedirektorin, Projektmanagement - Hr. F. Bergmann - stellv. Pflegedirektor; Qualitätsmanagement - Fr Mohm - Laborleitung, Hr. P. Schmusch (LKH), Hr. T. Weber

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

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

Konzept und Leitlinie (22.07.2022)

RM04

Clinical emergency management

MegaCode Training; SOP Notfallteam (19.07.2023)

RM05

Pain management

Leitlinie Schmerzmanagement (26.03.2018)

RM06

Fall prophylaxis

Leitlinie Sturzprophylaxe (01.02.2022)

RM07

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

Standard (27.10.2020)

RM08

Regulated handling of custodial measures

Verfahrensanweisung (19.05.2023)

RM09

Regulated handling of occurring malfunctions of devices

Meldung per Ticketsystem; Störmeldeformular (01.02.2022)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
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

PräOP Besprechung_Risk (11.09.2023)

RM15

Preoperative, complete presentation of necessary findings

Prä und Intra OP_Befundansicht (11.09.2023)

RM16

Procedure to avoid procedural and patient mix-ups

OP Checkliste; PräOP-Einleitung -Team Time Out (30.06.2022)

RM18

Discharge management

Entlassmanagement (05.09.2022)

Fault reporting systems

Conference committee

Conference frequency: bei Bedarf

Measures

bei Bedarf

No. Explanation
IF01

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

As of: 02.09.2022

IF02

Internal evaluation of the received reports

taken monatlich

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: 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)