Dealing with risks in patient care

Quality management

Maren Limbach

Qualitätsmanagementbeauftragte

Sophie-Henschel Weg 4
34260 Kaufungen

Phone: 0561 -3086-2110
Mail: ed.tiehdnuseg-soileh@hcabmil.neram

Zentral über den Standort Wehlheiden

Conference frequency: bei Bedarf

Risk management

Maren Limbach

Qualitätsmanagementbeauftragte

Sophie Henschel Weg 2
34260 Kaufungen

Phone: 0561 -3086-2110
Fax: 0561-3086-2004
Mail: ed.tiehdnuseg-soileh@hcabmil.neram

Zentral über den Standort Wehlheiden

Conference frequency: bei Bedarf

Risk management instruments and measures

No. Explanation
RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

im zentralen QM-Handbuch hinterlegt (24.11.2022)

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

im zentralen QM-Handbuch hinterlegt (05.06.2023)

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

  • 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

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

im zentralen QM-Handbuch hinterlegt (19.10.2022)

RM18

Discharge management

im zentralen QM-Handbuch hinterlegt (12.02.2020)

Fault reporting systems

Conference committee

Conference frequency: bei Bedarf

Measures

Schulungen; Veränderung in Abläufen; Anwendung neuer Gerätschaften und Techniken

No. Explanation
IF01

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

As of: 17.08.2023

IF02

Internal evaluation of the received reports

taken bei Bedarf

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
EF03

KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors)