Dealing with risks in patient care
Quality management
Martin Wilke
Leitung Qualitätsmanagement
Robert-Koch-Straße 1
84034 Landshut
Phone:
0871
-698-13635
Mail:
ed.tuhsdnal-mukinilk@tnemeganamsteatilauq
QM Steuergruppe mit QMB Pflege, QMB Ärzte, QMB Verwaltung, zentrales QM, kRM, Betriebsrat
Conference frequency: quartalsweise
Risk management
Susanne Ecker
Klinische Risikomanagerin
Phone:
0871
-698-3742
Fax: 0871-698-12632
Mail:
ed.tuhsdnal-mukinilk@rekce.ennasus
QM Steuergruppe mit QMB Pflege, QMB Ärzte, QMB Verwaltung, zentrales QM, kRM, Betriebsrat
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available z. B. Dienstanweisung klinisches Risikomanagement (10.08.2023) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management SOP Innerklinischer Notfall (09.12.2024) |
| RM05 |
Pain management z.B. Expertenstandard akuter Schmerz (12.04.2023) |
| RM06 |
Fall prophylaxis Expertenstandard Sturzprophylaxe (25.09.2024) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Pflegestandard Dekubitusprophylaxe (28.04.2025) |
| RM08 |
Regulated handling of custodial measures Durchführung Freiheitsentziehender Maßnahmen (FeM) (24.04.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices z.B. Dienstanweisung MPBetreibV (18.03.2025) |
| 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 z.B. Patientenorientiertes Blutmanagement (27.03.2025) |
| RM15 |
Preoperative, complete presentation of necessary findings z.B. Perioperatives Management (09.04.2024) |
| RM16 |
Procedure to avoid procedural and patient mix-ups z.B. Identitätssicherung und Vermeidung von Patienten und Seitenverwechslung an der Patienteneinschleuse zum OP (23.10.2023) |
| RM17 |
Standards for recovery and postoperative care z. B. Perioperatives Management (09.04.2024) |
| RM18 |
Discharge management Entlassmanagement (16.12.2024) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Schulung der MA für AED, Ausstattung des Neubaus mit AED, Erweiterung Monitore für ZNA, Ersatz der Piepseranlage durch neue Telefone.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 19.07.2023 |
| 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 Association, German Nursing Council, German Medical Association) |