Dealing with risks in patient care
Quality management
Elisabeth Waltrich
QMB
Wilferdinger Straße 67
75179 Pforzheim
Phone:
07231
-498-5640
Mail:
ed.haolis@hcirtlaW.htebasilE
Pflegedienst, ärztlicher Dienst, Rechnungswesen, QRM-Abteilung integriert durch Leitung QRM in Leitungsgremium
Conference frequency: monatlich
Risk management
zertifizierte klinische Risikomanager, CIRS-Mitglieder
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikopolitik und Risikostrategie (06.07.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Internes Notfallmanagement (28.01.2025) |
| RM05 |
Pain management Expertenstandard Schmerzmanagement in der Pflege bei chronischen und akuten Schmerzen (05.07.2024) |
| RM06 |
Fall prophylaxis Expertenstandard Sturzprophylaxe (21.09.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitusprophylaxe (28.01.2025) |
| RM08 |
Regulated handling of custodial measures Durchführung von Zwangsmaßnahmen / Freiheitsentziehende Maßnahmen (10.09.2025) |
| RM09 |
Regulated handling of occurring malfunctions of devices Störmeldung und Reparaturanforderung (26.07.2024) |
| 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 Sicherheitscheckliste OP-Bereich nach WHO (12.09.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings Checkliste OP-Vorbereitung auf Station (23.01.2025) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Nutzung von Identifikationsbändern für Patienten (15.04.2025) |
| RM17 |
Standards for recovery and postoperative care Schmerztherapie bei Erwachsenen und Kindern im Aufwachraum (27.07.2022) |
| RM18 |
Discharge management Entlassmanagement –Ärztlicher Dienst und Pflegedienst (30.09.2025) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Maßnahmen bei Ausfall des Schließsystems, Verfügbarkeit der Aufzüge bei medizinischen Notfällen, Wegbeschreibung für Mitglieder des Notfallteams
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 09.08.2024 |
| 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 jährlich |
Conference committee
Conference frequency: monatlich
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |