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Rottal-Inn Klinik Simbach am Inn - Psychosomatische Fachklinik

Dealing with risks in patient care

Quality management

Responsible person

Frau Julia Grieser

Qualitätsmanagementbeauftragte

Plinganserstraße 10
84359 Simbach am Inn

Phone: 08721 -983-2120
Mail: ed.nekinilknnilattor@ailuj.reseirg

Steering committee

Das Qualitätsmanagement der Rottal-Inn Kliniken ist als Stabstelle dem Vorstand unterstellt. Es erfolgt hier eine enge Zusammenarbeit mit allen Abteilungen der Rottal-Inn Kliniken. Entscheidungen im Rahmen des Qualitätsmanagements werden in direkter Absprache mit dem Vorstand getroffen.

Conference frequency: wöchentlich

Risk management

Responsible person

Julia Grieser

Qualitätsmanagementbeauftragte

Plinganserstraße 10
84359 Simbach am Inn

Phone: 08721 -983-2120
Fax: 08721-983-2124
Mail: ed.nekinilknnilattor@ailuj.reseirg

Steering committee

Vorstände, Qualitätsmanagement, Pflegedirektorin, Ärztlicher Direktor, Abteilungsleiter Finanzen und Patientenmanagement, Abteilungsleiter Zentraleinkauf/Technik/Wirtschafts- und Versorgungsdienst, Personalleiter, sowie weitere Fachexperten bei Bedarf

Conference frequency: quartalsweise

Risk management instruments and measures

Instruments and measures

No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM-Handbuch, Handbuch Risikomanagement (25.07.2022)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Alarm-und Einsatzplan, Notfallorganisation (12.06.2023)
RM05	Pain management Empfehlungen zur Schmerztherapie (02.05.2023)
RM06	Fall prophylaxis Expertenstandard Sturzprophylaxe in der Pflege (29.06.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitusprophylaxe (21.12.2021)
RM08	Regulated handling of custodial measures Fixierungsdienstanweisung (10.11.2022)
RM09	Regulated handling of occurring malfunctions of devices Dienstanweisung Medizintechnik (23.09.2022)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Palliativbesprechungen Qualitätszirkel
RM12	Use of standardised information sheets
RM18	Discharge management Einwilligung/Patienteninformation/Initialassessment (08.05.2023)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Es konnten in verschiedenen Bereichen der Kliniken Themen aus gemeldeten Fehlern und Beinahe-Fehlern heraus verbessert werden.

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 05.05.2023
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 bei Bedarf

No.

Explanation

IF01

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

As of: 05.05.2023

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 bei Bedarf

Across all institutions

Conference committee

Conference frequency: andere Frequenz

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)