Dealing with risks in patient care
Quality management
Dr. Andor Toth
Geschäftsführer
Uhlandstr. 2
78727 Oberndorf a.N.
Phone:
07423
-813-222
Mail:
ed.hrs@htoT.rodnA
Verwaltung, Qualitätsmanagement, betroffene Bereiche
Conference frequency: monatlich
Risk management
Verwaltung, Qualitätsmanagement, betroffene Bereiche
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available PB 1.4.6 Risiko- und ChancenmanagementPB 1.0.9 Chancen- und Risikobericht (14.08.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management PB NotfallmanagementStandard-Innerklinische ReanimationStandard-PostreanimationsbehandlungStandard-Reanimation auf ITS-IMC (14.09.2022) |
| RM05 |
Pain management PB 5.0.1 PCA-SchmerzkatheterVA 5.0.3 Periphere Regionalanästhesie (11.11.2022) |
| RM06 |
Fall prophylaxis Allgemeine Pflege Expertenstandard-Sturz, Anlage zum Expertenstandard-Sturz, Flyer Patienteninformation zur Sturzvermeidung (22.07.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard-Dekubitusprophylaxe in der Pflege (28.07.2021) |
| RM08 |
Regulated handling of custodial measures Allgemeine Pflege-Freiheitsentziehende MaßnahmenAllgemeine Pflege-Fixierungsprotokoll (02.10.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices MT-HO Handout Störmeldungen MedizintechnikPB InstandhaltungPB Wartung in Eigenleistung (Haustechnik) (22.07.2022) |
| 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 OP.-Statut (21.03.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings Durchführungsanweisung OP- SicherheitschecklisteVA 5.0.1 AnästehesievorbereitungsgesprächVA 5.0.8 Ambulante Patienten in der AnästhesiePB 4.0.1 AnamnesePB 4.0.2 Chirurgische Aufklärung (02.10.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups VA Anwendung PatientenarmbandPB Anwendung PatientenarmbandKOB Durchführungsanweisung OP- Sicherheitscheckliste (13.09.2023) |
| RM17 |
Standards for recovery and postoperative care Ablauf-AWRCell-Saver-Verfahrensanleitung (18.10.2022) |
| RM18 |
Discharge management PB-Entlassmanagement (10.02.2022) |
Fault reporting systems
Conference committee
Conference frequency: wöchentlich
Measures
Umfangreiche Maßnahmen z.B. im Bereich Hygiene, OP, Pflege, Medizintechnik, Patientenarmbänder, regelmäßige interne Audits zur Patientensicherheit, Kontrolle der Checklisten und Schulungen von Mitarbeitern (Auswärts, vor Ort oder durch das CNE-Portal/Integrity- Portal)
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 11.08.2022 |
| 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: 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) |