Dealing with risks in patient care

Quality management

Karin Normann-Koletnig

Qualitätsmanagement

Krankenhausstraße 15
85221 Dachau

Phone: 08131 -76-238
Mail: ed.tiehdnuseg-soileh@gintelok-nnamron.nirak

Maria Reischl-Weitzel

Qualitätsmanagement

Krankenhausstraße 15
85221 Dachau

Phone: 08131 -76-237
Mail: ed.tiehdnuseg-soileh@leztiew-lhcsier.airam

Conference frequency:

Risk management

Hjalmar Hagedorn

Ärztlicher Direktor

Phone: 08131 -76-4900
Fax: 08131-76-4909
Mail: ed.tiehdnuseg-soileh@nrodegah.ramlajh

Conference frequency:

Risk management instruments and measures

No. Explanation
RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Verfahrensanweisung Herzalarm (19.11.2019)

RM05

Pain management

Handlungsempfehlung Schmerzmanagement in der Pflege bei akuten und chronischen Schmerzen (01.09.2019)

RM06

Fall prophylaxis

Beschluss der FG Pflege Sturzprophylaxe (01.02.2023)

RM07

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

Beschluss der FG Pflege Dekubitusprophylaxe (01.11.2021)

RM08

Regulated handling of custodial measures

Handlungsempfehlung Fixierung (21.11.2014)

RM09

Regulated handling of occurring malfunctions of devices

Verfahrensstandard Umgang mit Produktproblemen (ZD Einkauf) (29.05.2015)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Qualitätszirkel
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

Konzernregelung OP-Sicherheit (27.01.2022)

RM15

Preoperative, complete presentation of necessary findings

Konzernregelung OP-Sicherheit (27.01.2022)

RM16

Procedure to avoid procedural and patient mix-ups

Konzernregelung OP-Sicherheit (27.01.2022)

RM17

Standards for recovery and postoperative care

Verfahrensanweisung postoperative Pflege (10.04.2012)

RM18

Discharge management

Ärztliches Manual (30.03.2022)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Schulungen Patientensicherheit für Mitarbeiter; Fallbesprechungen; Verbesserung der Kommunikation

No. Explanation
IF01

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

As of: 17.07.2018

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

Other