Dealing with risks in patient care
Quality management
Andrea Sepperl
Qualitätsmanagement
Schützenstraße 15
83646 Bad Tölz
Phone:
08041
-507-1028
Mail:
moc.soipelksa@lreppes.na
Qualitätsmanagement, Geschäftsführung, Ärztlicher Direktor, Pflegedirektion, Patientenmanagement, Personalleitung
Conference frequency: andere Frequenz
Risk management
Ludger Karger
Betriebsrat
Schützenstraße 15
83646 Bad Tölz
Phone:
08041
-507-4053
Fax: 08041-507-1887
Mail:
moc.soipelksa@regrak.l
Florian Castrop
Leitender Oberarzt Neurologie
Schützenstraße 15
83646 Bad Tölz
Phone:
08041
-507-2002
Fax: 08041-507-2334
Mail:
moc.soipelksa@portsac.f
Qualitätsmanagement, Geschäftsführung, Ärztlicher Direktor, Pflegedirektion, Patientenmanagement, Personalleitung
Conference frequency: andere Frequenz
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Konzept Risiko- und Fehlermanagement (CIRS) in den Asklepios Kliniken Bad Tölz (09.06.2021) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Prozessbeschreibung Notfallmanagement (08.09.2022) |
| RM05 |
Pain management Expertenstandard Schmerz (04.03.2021) |
| RM06 |
Fall prophylaxis Expertenstandard Sturz (03.07.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitus (23.02.2022) |
| RM08 |
Regulated handling of custodial measures Leitlinie Umgang freiheitsentziehende Maßnahmen (04.09.2020) |
| RM09 |
Regulated handling of occurring malfunctions of devices Organisationshandbuch Medizintechnik (01.06.2021) |
| 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 Sicherheits-Checkliste OP (24.02.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings Leitlinie Präoperative Diagnostik (06.09.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Verfahrensanweisung Sichere Patientenidentifikation (10.06.2022) |
| RM17 |
Standards for recovery and postoperative care Leitlinie Postoperative interdisziplinäre Patientenversorgung (12.08.2019) |
| RM18 |
Discharge management Verfahrensanweisung Entlassmanagement (11.06.2021) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
regelmäßige MM-Konferenzen, regelmäßige Hygienebegehungen und -schulungen, Stop-Inject Check Projekt, OP-Checkliste, OP-Checkliste für kleine Eingriffe, Teilnahme am Tag der Patientensicherheit, Medical Board, Risikoaudits
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 18.06.2021 |
| 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: monatlich
| No. | Explanation |
|---|---|
|
Other |
|
| EF14 |
CIRS Health Care |