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
|
| 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) |