Dealing with risks in patient care
Quality management
Olga Platzer
Stabsstelle Qualitätsmanagement
Große Allee 50
34454 Bad Arolsen
Phone:
0561
-980-4960
Mail:
ten.hng@reztalp.aglo
Geschäftsführung, Stabsstelle QM und Organisation, QMB
Conference frequency: halbjährlich
Risk management
Olga Platzer
Stabsstelle Qualitätsmanagement
Große Allee 50
34454 Bad Arolsen
Phone:
0561
-980-4960
Mail:
ten.hng@reztalp.aglo
Geschäftsführung, Stabsstelle Qualitätsmanagement und Organisation, Qualitätsmanagementbeauftragte
Conference frequency: halbjährlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Rahmenkonzept Risikomanagement GNH; (03.04.2014) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Es existiert eine einheitliche hausinterne Notfallnummer. Das Vorgehen zur Reanimation folgt der VA 2015 ERC. Darüber hinaus existieren hausinterne Regelungen bspw. zur Bestückung von Notfallwagen. (24.06.2020) |
| RM05 |
Pain management Therapiestandard zur postoperativen Schmerztherapie (17.02.2020) |
| RM06 |
Fall prophylaxis Arbeitsanweisung Sturzprophylaxe in der Pflege (12.04.2020) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Richtlinie Dekubitusprophylaxe in der GNH (06.09.2021) |
| RM08 |
Regulated handling of custodial measures Richtlinie - Besondere Sicherungsmaßnahme Fixierung; Vorgaben zur Meldung an das Amtsgericht; Vorgaben zur Dokumentation von Maßnahmen (09.06.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Organisationshandbuch Medizintechnik für Anwender (24.08.2022) |
| 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 SOP Patientensicherheit im OP-Ablauf sowie diverse Checklisten (30.11.2016) |
| RM15 |
Preoperative, complete presentation of necessary findings SOP Patientensicherheit im OP-Ablauf (30.11.2016) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Verfahrensbeschreibung zur Prävention von Eingriffsverwechslungen (12.05.2020) |
| RM18 |
Discharge management Verfahrensregel zum Entlassungsmanagement (08.03.2022) |
Fault reporting systems
Conference committee
Conference frequency: halbjährlich
Measures
Benennung des Patientensicherheitsbeauftragten, Ausweitung OP-Checkliste, Regelmäßige Schulung der Teams
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 18.02.2016 |
| 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 bei Bedarf |
Conference committee
Conference frequency: halbjährlich
| 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) |
| EF13 |
DokuPIK (Documentation of Pharmaceutical Interventions in Hospitals at the Federal Association of German Hospital Pharmacists (ADKA) |