Dealing with risks in patient care
Quality management
Maren Limbach
Qualitätsmanagementbeauftragte
Hansteinstraße 29
34121 Kassel
Phone:
0561
-3086-2110
Mail:
ed.tiehdnuseg-soileh@hcabmil.neram
Geschäftsführung, Ärztlicher Direktor, Pflegedienstleitung, Betriebsrat
Conference frequency: bei Bedarf
Risk management
Maren Limbach
Qualitätsmanagementbeauftragte
Phone:
0561
-3086-2110
Fax: 0561-3086-2104
Mail:
ed.tiehdnuseg-soileh@hcabmil.neram
Geschäftsführung, Ärztlicher Direktor, Pflegedienstleitung, Betriebsrat
Conference frequency: bei Bedarf
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management im zentralen QM-Handbuch hinterlegt (24.11.2022) |
| RM05 |
Pain management Handlungsempfehlung Schmerzmanagement in der Pflege bei akuten und chronischen Schmerzen (01.09.2019) |
| RM06 |
Fall prophylaxis Beschluss der FG Pflege Sturzprophylaxe (01.02.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Beschluss der FG Pflege Dekubitusprophylaxe (01.11.2021) |
| RM08 |
Regulated handling of custodial measures im zentralen QM-Handbuch hinterlegt (05.06.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Verfahrensstandard Umgang mit Produktproblemen (ZD Einkauf) (29.05.2015) |
| 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 Konzernregelung OP-Sicherheit (27.01.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings Konzernregelung OP-Sicherheit (27.01.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Konzernregelung OP-Sicherheit (27.01.2022) |
| RM17 |
Standards for recovery and postoperative care im zentralen QM-Handbuch hinterlegt (19.10.2022) |
| RM18 |
Discharge management im zentralen QM-Handbuch hinterlegt (12.02.2020) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Schulungen; Veränderung in Abläufen; Anwendung neuer Gerätschaften und Techniken
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 17.08.2023 |
| IF02 |
Internal evaluation of the received reports taken bei Bedarf |
| 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: bei Bedarf
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors) |