Dealing with risks in patient care

Quality management

Christine Rebiger

Qualitätsmanagementbeauftragte

Am Waldrand 1
18209 Hohenfelde

Phone: 038203 -94-159
Mail: ed.anas@regiber.enitsirhc

Chefärzte, Pflegedienstleitung, Kaufmännische Leitung, Geschäftsführer, QMB

Conference frequency: quartalsweise

Risk management

Christine Rebiger

Qualitätsmanagementbeauftragte

Am Waldrand 1
18209 Hohenfelde

Phone: 038203 -94-159
Fax: 038203-94-111
Mail: ed.anas@regiber.enitsirhc

Ärztlicher Dienst, Pflegedienst, QMB

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 (01.10.2021)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Medizinische Notfälle; Ablaufschema Kardiopulmonale Reanimation (13.08.2021)

RM05

Pain management

QM-Handbuch (01.10.2021)

RM06

Fall prophylaxis

Standard E2 Sturzprophylaxe (15.02.2021)

RM07

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

Pflegestandard Dekubitusprophylaxe (03.11.2021)

RM08

Regulated handling of custodial measures

Freiheitsentziehende Maßnahmen; Fixierungsanordnung und -protokoll (01.07.2021)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Pathologiebesprechungen
  • wöchentliche Fallbesprechung
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

Sicherheits-Checkliste Chirurgie (15.07.2021)

RM15

Preoperative, complete presentation of necessary findings

Arbeitsanweisung zum allgemeinen Ablauf bei allen ambulanten Operationen im Krankenhaus (03.11.2021)

RM16

Procedure to avoid procedural and patient mix-ups

Sicherheits-Checkliste Chirurgie, Verwendung von Patientenarmbändern (19.05.2021)

RM17

Standards for recovery and postoperative care

Postoperative Prozesse und Pflegestandards (01.03.2021)

RM18

Discharge management

Qualitätssicherungsmaßnahmen Ambulantes Operieren / Entlassung nach Hause; Schritte des Entlassungsmanagements (03.11.2021)

Fault reporting systems

Conference committee

Conference frequency: quartalsweise

Measures

z.B. Schulungsmaßnahmen

No. Explanation
IF01

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

As of: 12.08.2019

IF02

Internal evaluation of the received reports

taken quartalsweise

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: quartalsweise

No. Explanation
EF03

KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association)