Dealing with risks in patient care
Quality management
Dipl.-Betriebswirt (FH) Christian Engert
Qualitätsmanagementleiter
Balthasar-Neumann-Platz 1
97440 Werneck
Phone:
09722
-21-1888
Mail:
ed.kcenrew-ssolhcs-hk@tregne.naitsirhc
Krankenhausdirektion Ärztlicher Direktor Pflegedirektion Qualitätsmanagementleitung
Conference frequency: monatlich
Risk management
Christian Engert
Qualitätsmanagementleiter
Balthasar-Neumann-Platz 1
97440 Werneck
Phone:
09722
-21-1888
Mail:
ed.kcenrew-ssolhcs-hk@tregne.naitsirhc
Krankenhausdirektion Ärztlicher Direktor Pflegedirektion Qualitätsmanagementleitung
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available "Risikomanagementkonzept" (26.01.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management "Stationärer Notfall" (25.07.2023) |
| RM05 |
Pain management "Postoperative Schmerztherapie" (11.04.2019) |
| RM06 |
Fall prophylaxis "Standard Sturz" (19.01.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) "Standard Dekubitus" (15.01.2021) |
| RM08 |
Regulated handling of custodial measures "Umgang mit freiheitsentziehenden Maßnahmen" (21.01.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices "Organisationshandbuch Medizintechnik" (18.09.2019) |
| 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 "Schnittstellen-Management-Bogen" (23.11.2020) |
| RM16 |
Procedure to avoid procedural and patient mix-ups "Handlungsanleitung Schnittstellen-Management-Bogen" (01.07.2019) |
| RM17 |
Standards for recovery and postoperative care "Übernahme eines Patienten auf den Aufwachraum/IMC" (29.07.2023) |
| RM18 |
Discharge management "Risikomanagementkonzept" (26.01.2022) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
z. B. Einführung Team-Time-Out
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.01.2021 |
| 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 jährlich |
Conference committee
Conference frequency: monatlich
| No. | Explanation |
|---|---|
| EF01 |
CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association, National Association of Statutory Health Insurance Doctors) |
| EF02 |
CIRS Berlin (Medical Association Berlin, German Medical Association, National Association of Statutory Health Insurance Doctors) |
| EF03 |
KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors) |