Dealing with risks in patient care
Quality management
Frau Christine Koop
Qualitätsmanagementbeauftragte
Schiffdorfer Chaussee 29
27574 Bremerhaven
Phone:
0049471
-182-1856
Mail:
ed.soema@pook.enitsirhc
Krankenhausdirektion, Ärztliche Direktion, Pflegerische Direktion, Qualitätsmanagement
Conference frequency: monatlich
Risk management
Stefan Gronholz
Krankenhausdirektor seit 01.04.2025, vorher Katja Loesche
Schiffdorfer Chaussee 29
27574 Bremerhaven
Phone:
0049471
-182-1317
Fax: 0049-182471-1370
Mail:
ed.soema@zlohnorg.nafets
Krankenhausdirektion, Ärztliche Direktion, Pflegerische Direktion, Qualitätsmanagement
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available OP Sicherheitscheckliste (01.05.2024) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management OP Sicherheitscheckliste (01.05.2024) |
| RM05 |
Pain management OP Sicherheitscheckliste (01.05.2024) |
| RM06 |
Fall prophylaxis OP Sicherheitscheckliste (01.05.2024) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) OP Sicherheitscheckliste (01.05.2024) |
| RM08 |
Regulated handling of custodial measures OP Sicherheitscheckliste (01.05.2024) |
| RM09 |
Regulated handling of occurring malfunctions of devices OP Sicherheitscheckliste (01.05.2024) |
| 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 OP Sicherheitscheckliste (01.05.2024) |
| RM15 |
Preoperative, complete presentation of necessary findings OP Sicherheitscheckliste (01.05.2024) |
| RM16 |
Procedure to avoid procedural and patient mix-ups OP Sicherheitscheckliste (01.05.2024) |
| RM17 |
Standards for recovery and postoperative care OP Sicherheitscheckliste (01.05.2024) |
| RM18 |
Discharge management OP Sicherheitscheckliste (01.05.2024) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
z. B. OP Checklisten, Patientenarmbänder, Risikoaudits
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 17.06.2024 |
| 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: monatlich
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |