Dealing with risks in patient care

Quality management

Rene Schaffarczyk

Qualitäts- und Risikomanagement Beauftragter

Neumeyerstr. 46-48
90411 Nürnberg

Phone: 0911 -58068-1212
Mail: moc.knilk013@kyzcraffahcs.ener

Liliya Kudayeva

Qualitäts- und Risikomanagement Beauftragte

Neumeyerstr. 46-48
90411 Nürnberg

Phone: 0911 -58068-0
Mail: moc.knilk013@ofni

QM

Conference frequency: quartalsweise

Risk management

Rene Schaffarczyk

Qualitäts- und Risikomanagement Beauftragter

Neumeyerstraße 46-48
90411 Nürnberg

Phone: 0911 -58068-1212
Fax: 0911-58068-1650
Mail: moc.knilk013@kyzcraffahcs.ener

Liliya Kudayeva

Qualitäts- und Risikomanagement Beauftragte

Neumeyerstraße 46-48
90411 Nürnberg

Phone: 0911 -58068-0
Fax: 0911-58068-1150
Mail: moc.knilk013@ofni

QM

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

Comprehensive quality and/or risk management documentation (QM/RM documentation) is available

QM Auditierung ISO 9001:2015 durch TÜV (27.06.2023)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

SOP Notfallmanagement (11.10.2022)

RM05

Pain management

Qualitäts- und Risikomanagementhandbuch (17.03.2022)

RM06

Fall prophylaxis

Qualitäts- und Risikomanagementhandbuch (17.03.2022)

RM07

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

Qualitäts- und Risikomanagementhandbuch (17.03.2022)

RM08

Regulated handling of custodial measures

Qualitäts- und Risikomanagementhandbuch (17.03.2022)

RM09

Regulated handling of occurring malfunctions of devices

Qualitäts- und Risikomanagementhandbuch (17.03.2022)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Röntgenkonferenz
  • Intensivtherapiekonferenz
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

Qualitäts- und Risikomanagementhandbuch (17.03.2022)

RM15

Preoperative, complete presentation of necessary findings

Qualitäts- und Risikomanagementhandbuch (17.03.2022)

RM16

Procedure to avoid procedural and patient mix-ups

Qualitäts- und Risikomanagementhandbuch (17.03.2022)

RM17

Standards for recovery and postoperative care

Qualitäts- und Risikomanagementhandbuch (17.03.2022)

RM18

Discharge management

Qualitäts- und Risikomanagementhandbuch (17.03.2022)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Markierung der Patienten vor OP durch den behandelnden Arzt, Patientenarmband, mehrsprachige Information zur Nüchternheit vor OP

No. Explanation
IF01

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

As of: 21.06.2022

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 jährlich

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)