Dealing with risks in patient care
Quality management
Nina Breyer
Abteilungsleitung Qualitätsmanagement (seit 01.10.2023)
Virchowstr. 10
78224 Singen
Phone:
07531
-801-2270
Mail:
ed.nklg@reyerb.anin
Geschäftsführung, kaufmännische Direktion, Direktion Medizin und Pflege, Pflegedirektion, Ärztl. Direktion, Verbundbetriebsrat, Qualitätsmanagement, Leitungen der Bereiche Technik/Bau, Krankenhaushygiene, Medizinisches Controlling und Servicegesellschaft.
Conference frequency: quartalsweise
Risk management
Nina Breyer
Abteilungsleitung Qualitätsmanagement (seit 01.10.2023)
Virchowstraße 10
78224 Singen
Phone:
07531
-801-2270
Mail:
ed.nklg@reyerb.anin
Geschäftsführung, kaufmännische Direktion, Direktion Medizin und Pflege, Pflegedirektion, Ärztl. Direktion, Verbundbetriebsrat, Qualitätsmanagement, Leitungen der Bereiche Technik/Bau, Krankenhaushygiene, Medizinisches Controlling und Servicegesellschaft.
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM-Handbuch GLKN (18.04.2024) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management QM-Handbuch GLKN (07.04.2022) |
| RM05 |
Pain management QM-Handbuch GLKN (29.12.2023) |
| RM06 |
Fall prophylaxis QM-Handbuch GLKN (10.12.2020) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) QM-Handbuch GLKN (10.12.2020) |
| RM08 |
Regulated handling of custodial measures QM-Handbuch GLKN (03.02.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices QM-Handbuch GLKN (10.12.2020) |
| 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 QM-Handbuch GLKN (24.05.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings QM-Handbuch GLKN (24.05.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups QM-Handbuch GLKN (24.05.2022) |
| RM17 |
Standards for recovery and postoperative care QM-Handbuch GLKN (24.05.2022) |
| RM18 |
Discharge management QM-Handbuch GLKN (16.08.2024) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Aus CIRS heraus werden fortlaufend zahlreiche Verbesserungsmaßnahmen abgeleitet
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 27.03.2024 |
| 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 bei Bedarf |
Conference committee
Conference frequency: jährlich
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |