Dealing with risks in patient care

Quality management

Rebecca Maria Geis

Qualitätsbeauftragte

Goethestraße 4
35423 Lich

Phone: 06404 -81-611
Mail: moc.soipelksa@sieg.r

Geschäftsführung, Klinikmanagerin, Ärztlicher Direktor, stv. Ärztlicher Direktor, Pflegedienstleitung, QMB

Conference frequency: quartalsweise

Risk management

Rebecca Maria Geis

Qualitätsbeauftragte

Goethestr. 4
35423 Lich

Phone: 06404 -81-611
Fax: 06404-81-485
Mail: moc.soipelksa@sieg.r

Geschäftsführung, Klinikmanagerin, Ärztlicher Direktor, stv. Ärztlicher Direktor, Pflegedienstleitung, QMB

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

Comprehensive quality and/or risk management documentation (QM/RM documentation) is available

Konzept Klinisches Risikomanagement (23.03.2023)

RM02

Regular further education and training measures

RM04

Clinical emergency management

Konzept Notfallmanagement (11.08.2023)

RM05

Pain management

Schmerzdokumentation und -therapie (Standard) (10.08.2022)

RM06

Fall prophylaxis

Standard Sturzprophylaxe (13.07.2023)

RM07

Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”)

Standard Dekubitusprophylaxe (11.08.2021)

RM08

Regulated handling of custodial measures

Verfahrensanweisung Durchführung freiheitsentziehender Maßnahmen (07.06.2020)

RM09

Regulated handling of occurring malfunctions of devices

Störmeldung Meldung von defekten Medizingeräten u. Vorkommnis Medizintechnik (30.09.2020)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Pathologiebesprechungen
  • Palliativbesprechungen
  • Onkologische Pflege Fallbesprechungen
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

OP-Sicherheitscheckliste (10.10.2023)

RM15

Preoperative, complete presentation of necessary findings

OP-Sicherheitscheckliste (10.10.2023)

RM16

Procedure to avoid procedural and patient mix-ups

Verfahrensanweisung Vermeidung einer Eingriffsverwechslung (23.03.2023)

RM17

Standards for recovery and postoperative care

Standard Aufwachraum/Anordnung Station (23.03.2023)

RM18

Discharge management

Standard Entlassungsmanagement (03.09.2022)

Fault reporting systems

Conference committee

Conference frequency: quartalsweise

Measures

z.B. interne und externe Audits

No. Explanation
IF01

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

As of: 23.03.2023

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 monatlich

Conference committee

Conference frequency: quartalsweise

No. Explanation

Other

EF14

CIRS Health Care