Dealing with risks in patient care
Quality management
Gabriele Damm
Leitung Qualitäts- und Risikomanagement
Janusz-Korczak-Allee 12
30173 Hannover
Phone:
0511
-8115-2712
Mail:
ed.akh@mmad
Vorständin, Ärztliche Direktorin, Pflegedirektor, Kaufmännischer Direktor, Einrichtungsleitungen, Qualitäts- und Risikomanagement, Betriebsrat
Conference frequency: quartalsweise
Risk management
Agnes Genewein
Vorständin Hannoversche Kinderheilanstalt
Janusz-Korczak-Allee 12
30173 Hannover
Phone:
0511
-8115-1111
Fax: 0511-8115-1112
Mail:
ed.akh@nieweneg.senga
Vorständin, Ärztliche Direktorin, Pflegedirektor, Kaufmännischer Direktor, Einrichtungsleitungen, Qualitäts- und Risikomanagement, Betriebsrat
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM-Organisationshandbuch (20.07.2023) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management QM-Organisationshandbuch (20.07.2023) |
| RM05 |
Pain management QM-Organisationshandbuch (20.07.2023) |
| RM06 |
Fall prophylaxis QM-Organisationshandbuch (20.07.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) QM-Organisationshandbuch (20.07.2023) |
| RM08 |
Regulated handling of custodial measures QM-Organisationshandbuch (20.07.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices QM-Organisationshandbuch (20.07.2023) |
| 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 QM-Organisationshandbuch (20.07.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings QM-Organisationshandbuch (20.07.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups QM-Organisationshandbuch (20.07.2023) |
| RM17 |
Standards for recovery and postoperative care QM-Organisationshandbuch (20.07.2023) |
| RM18 |
Discharge management QM-Organisationshandbuch (20.07.2023) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Entsprechend der jeweiligen Fälle
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 20.07.2023 |
| 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: 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) |