Dealing with risks in patient care
Quality management
Dipl.-Kffr. Sarah Sebeke
Krankenhausleitung
Kirchstraße 61 - 67
26789 Leer
Phone:
0491
-85-80000
Mail:
ed.reel-latipsoh@gnutielstfeahcseg
Geschäftsführung, Kfm. Direktor, stv. Kfm. Direktorin, Pflegedirektor, stv. Pflegedirektor, Ärztlicher Direktor, stv. Ärztlicher Direktor, Qualitätsmanagementbeauftragte
Conference frequency: bei Bedarf
Risk management
Claudia Liebetrau
Qualitätsmanagement u. Organisationsentwicklung
Kirchstraße 61-67
26789 Leer
Phone:
0491
-85-80300
Fax: 0491-85-80009
Mail:
ed.reel-latipsoh@uartebeil.aidualc
Risikomanagement, Ärztlicher Dienst, Anästhesie u. Intensivmedizin), Gesundheits- und Krankenpflege (periphere Station, OP-Abteilung, Intensivstation, Anästhesie), Mitarbeitervertretung, Pflegedirektion, Technische Abteilung/Medizintechnik
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikomanagementkonzept (26.08.2019) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Risikomanagementkonzept (26.08.2019) |
| RM05 |
Pain management Risikomanagementkonzept (26.08.2019) |
| RM06 |
Fall prophylaxis Expertenstandard Sturz (18.02.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitusprophylaxe in der Pflege (06.12.2016) |
| RM08 |
Regulated handling of custodial measures Verfahrensanweisung Freiheitsentziehende Maßnahmen (22.11.2018) |
| RM09 |
Regulated handling of occurring malfunctions of devices Umgang mit defekten Medizinprodukten (21.01.2016) |
| 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 Verfahrensanweisung „Standardprozeduren und Patientensicherheit im OP", OP-Statut (10.08.2018) |
| RM15 |
Preoperative, complete presentation of necessary findings OP Checkliste (01.05.2018) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Risikomanagementkonzept (26.08.2019) |
| RM17 |
Standards for recovery and postoperative care Risikomanagementkonzept (26.08.2019) |
| RM18 |
Discharge management Konzept Entlassungsmanagement (24.02.2015) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Risikomanagementkonzept, Geschäftsordnung Risikomanagementteam, Nutzung der WHO OP-Checkliste, Prozessbeschreibungen und Patienten-Informationen für Patientenarmbänder, Room of Horrors, Maßnahmen zur Erhöhung der AMTS, etc.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 29.03.2017 |
| 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 Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors) |