Dealing with risks in patient care
Quality management
Dr. Nils Löber
Leiter Klinisches Qualitäts-und Risikomanagement
Charitéplatz 1
10117 Berlin
Phone:
030
-450577-046
Mail:
ed.etirahc@rebeol.slin
Dr. Sibylle Semmler
Leitung Klinisches Qualitäts-und Risikomanagement
Charitéplatz 1
10117 Berlin
Phone:
030
-450-50
Mail:
ed.etirahc@relmmes.ellybis
Stabsstelle des Vorstands Krankenversorgung: Klinisches Qualitäts- und Risikomanagement
Conference frequency: wöchentlich
Risk management
Nils Löber
Leiter Klinisches Qualitäts-und Risikomanagement
Charitéplatz 1
10117 Berlin
Phone:
030
-450577-046
Fax: 030-450577-7046
Mail:
ed.etirahc@rebeol.slin
Sibylle Semmler
Leitung Klinisches Qualitäts-und Risikomanagement
Charitéplatz 1
10117 Berlin
Phone:
030
-450-50
Fax: 030-4507514-041
Mail:
ed.etirahc@relmmes.ellybis
Stabsstelle des Vorstands Krankenversorgung: Klinisches Qualitäts- und Risikomanagement
Conference frequency: wöchentlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Zentrales QM Handbuch (31.12.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Zentrales QM Handbuch (31.12.2022) |
| RM05 |
Pain management Zentrales QM Handbuch (31.12.2022) |
| RM06 |
Fall prophylaxis Zentrales QM Handbuch (31.12.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Zentrales QM Handbuch (31.12.2022) |
| RM08 |
Regulated handling of custodial measures Zentrales QM Handbuch (31.12.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Zentrales QM Handbuch (31.12.2022) |
| 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 Zentrales QM Handbuch (31.12.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings Zentrales QM Handbuch (31.12.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Zentrales QM Handbuch (31.12.2022) |
| RM17 |
Standards for recovery and postoperative care Zentrales QM Handbuch (31.12.2022) |
| RM18 |
Discharge management Zentrales QM Handbuch (31.12.2022) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Zusätzliche Kennzeichnung Defi Pads, Prozessoptimierung Blutprobenabholung ZNA
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 30.04.2022 |
| 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 monatlich |
Conference committee
Conference frequency: quartalsweise
| No. | Explanation |
|---|---|
| EF02 |
CIRS Berlin (Medical Association Berlin, German Medical Association, National Association of Statutory Health Insurance Doctors) |
| EF03 |
KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors) |