Dealing with risks in patient care
Quality management
Dipl.-Kffr. (FH) Birgit Stühmeier
QMB
Bavariaring 46
80336 München
Phone:
089
-1304-2215
Mail:
ed.noitkeridsuahneknark@reiemheuts.tigrib
Oberarzt Chirurgie- Zentrumsleiter, -Koordinator, Ärztlicher Direktor, PDL, QMB und Verwaltungsdirektor
Conference frequency: quartalsweise
Risk management
Oberarzt Chirurgie- Zentrumsleiter, -Koordinator, Ärztlicher Direktor, PDL, QMB und Verwaltungsdirektor
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitätsmanagementhandbuch (01.06.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Herzkreislaufstillstand - Reanimation (SOP_54 Stand 06/2021), Medizinischer Notfall (VA_72 Stand 3/2023) Herzalarm (SOP_65 Stand 12/2022) Notfallplan (SOP_81 Stand 12/2022) Frühwarnsystem Sepsis (SOP_99 Stand 06/2024) (01.06.2024) |
| RM05 |
Pain management Postoperative Schmerztherapie (SOP_73) (01.06.2023) |
| RM06 |
Fall prophylaxis Sturzprophylaxe (ST_12 Stand 11/2023) Sturzereignis (ST_11 Stand 04/2023) Patienteninfo zur Sturzprophylaxe (IN_6 Stand 10/2021) (01.11.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusprophylaxe Expertenstandard ST_9 (01.02.2020) |
| RM08 |
Regulated handling of custodial measures Freiheitsentziehende Maßnahmen (FEM) (ST_57 Stand 6/2021) Dokumentation FEM (FO_194 Stand 2/2023) (03.01.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Organisationshandbuch Medizintechnik Stand 08/2012; Umgang mit defekten Geräten VA_88 Stand 06/2023 (01.06.2023) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM13 |
Application of standardised surgical check lists |
| RM16 |
Procedure to avoid procedural and patient mix-ups Überprüfung der der Patientenidentifikation vor Untersuchungen u.a. Sicherheitscheckliste nach WHO (01.05.2019) |
| RM17 |
Standards for recovery and postoperative care Überwachung im Aufwachraum ST_92 Stand 06/2023 (01.06.2023) |
| RM18 |
Discharge management Entlassmanagement-Entlassplan (FO_129 Stand 01/2022) Entlassung in amb/stat. Pflegeeinrichtung (VA_95 Stand 09/2023) Entlassung in AHB (VA_96 Stand 09/2023) (01.09.2023) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Verbesserung/Anpassung von Prozessen im Krankenhaus (z.B. pflegerische Patientenaufnahme) Schulungen für Personal
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.10.2022 |
| 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: