Dealing with risks in patient care
Quality management
Fritz Dietel
QMB
Hartensteiner Straße 42
09350 Lichtenstein
Phone:
0371
-8321060-
Mail:
ed.shk-krd@ztirf.leteid
Qualitätszirkel finden interdisziplinär statt. Die Teilnahme von Verwaltung, Pflegedienstleitung u. ärztl. Vertretern gewährleistet die umfassende Bearbeitung der Projekte. Bei Bedarf werden diese im Rahmen verschiedener Gremien besprochen (z. B. Chefarztberatung, Betriebsleitung, Stationsleitung).
Conference frequency: quartalsweise
Risk management
Falk Wagner
Risikomanagementbeauftragter, stellvert. Geschäftsführer
Hartensteiner Straße 42
09350 Lichtenstein
Phone:
0371
-832-1302
Mail:
ed.shk-krd@klaf.rengaw
Beteiligte Abteilungen / Funktionsbereiche: Geschäftsleitung, Betriebsleitung, QMB und weitere Beauftragte je nach Gattung der zu bearbeitenden Themen
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Managementhandbuch (10.08.2020) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Managementhandbuch (10.08.2020) |
| RM05 |
Pain management Managementhandbuch (10.08.2020) |
| RM06 |
Fall prophylaxis Expertenstandard Sturz (24.10.2019) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitus (19.07.2019) |
| RM08 |
Regulated handling of custodial measures Managementhandbuch (10.08.2020) |
| RM09 |
Regulated handling of occurring malfunctions of devices Managementhandbuch (10.08.2020) |
| 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 Managementhandbuch (10.08.2020) |
| RM15 |
Preoperative, complete presentation of necessary findings Managementhandbuch (10.08.2020) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Managementhandbuch (10.08.2020) |
| RM17 |
Standards for recovery and postoperative care Managementhandbuch (10.08.2020) |
| RM18 |
Discharge management Managementhandbuch (10.08.2020) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
verstärkte Schulungen bei Anwendungssoftware, bauliche Maßnahmen, Einführung des Patientenidentifikationsarmbandes, Leitfaden zu verschiedenen Risiko-Themen, Durchführen einer Risikoinventur
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 22.10.2020 |
| 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 quartalsweise |
Conference committee
Conference frequency: bei Bedarf
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |