To the hospital’s home page

Krankenhaus der Barmherzigen Brüder Trier

Dealing with risks in patient care

Quality management

Responsible person

Jörg Bohlen

Regionalbereichsleitung Qualitäts- u. Risikomanagement

Nordallee 1
54292 Trier

Phone: 0651 -208-1500
Mail: ed.reirt-kb@nelhob.j

Steering committee

Ca. 40 Mitarbeiter*innen nehmen in den Abt. und Bereichen derzeit die Aufgaben als QMBA wahr. In den Med. Fachabteilungen i. d. R. je ein Mitarbeiter der Pflege und ein ärztlicher Mitarbeiter. Die Organisation und Koordination der gemeinsamen Aktivitäten erfolgt durch den Regionalbereich QM & RM.

Conference frequency: bei Bedarf

Risk management

Responsible person

Thorsten Eich

Kaufm. Direktor

54215 Trier

Phone: 0651 -208-1206
Fax: 0651-208-1201
Mail: ed.reirt-kb@hcie.t

Steering committee

Für alle im Rahmen des Risikomanagements benannten Felder/ Bereiche sind Risikomanagement-Beauftragte benannt. Die Berichterstattung findet regelmäßig im Abstand von vier Monaten statt (Tagungsfrequenz des Gremiums etwa alle 4 Monate).

Conference frequency: andere Frequenz

Risk management instruments and measures

Instruments and measures

No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Organisationshandbuch (17.09.2021)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Organisationshandbuch (17.09.2021)
RM05	Pain management Organisationshandbuch (17.09.2021)
RM06	Fall prophylaxis Organisationshandbuch (17.09.2021)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Organisationshandbuch (17.09.2021)
RM08	Regulated handling of custodial measures Organisationshandbuch (17.09.2021)
RM09	Regulated handling of occurring malfunctions of devices Organisationshandbuch (17.09.2021)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Pathologiebesprechungen Qualitätszirkel Palliativbesprechungen
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 Organisationshandbuch (17.09.2021)
RM15	Preoperative, complete presentation of necessary findings Organisationshandbuch (17.09.2021)
RM16	Procedure to avoid procedural and patient mix-ups Organisationshandbuch (17.09.2021)
RM17	Standards for recovery and postoperative care Organisationshandbuch (17.09.2021)
RM18	Discharge management Organisationshandbuch (17.09.2021)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Im Rahmen der regelmäßig stattfindenden CIRS-Team Sitzungen werden die eingehenden Meldungen bearbeitet und bewertet sowie entsprechende Maßnahmen zur Verbesserung der Patientensicherheit abgeleitet und zur Umsetzung gebracht.

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 24.03.2023
IF02	Internal evaluation of the received reports taken halbjährlich
IF03	Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken quartalsweise

No.

Explanation

IF01

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

As of: 24.03.2023

IF02

Internal evaluation of the received reports

taken halbjährlich

IF03

Training of employees in handling the error reporting system and in implementing the findings from the error reporting system

taken quartalsweise

Across all institutions

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)