Dealing with risks in patient care

Quality management

Dr. med. Felix Große

Qualitätsmanagementbeauftragter Arzt

Jakob-Henle-Straße 1
90766 Fürth

Phone: 0911 -7580-1044
Mail: ed.htreuf-mukinilk@essorg.xilef

QM-Lenkungsgremium - Vorstand - Ärztlicher Direktor - Pflegedirektor - Zentrenkoordination - Leitung Unternehmensentwicklung - Qualitäts- & Risikomanagement-Beauftragte - Personalratsvorsitzende

Conference frequency: monatlich

Risk management

Felix Große

Qualitätsmanagementbeauftragter Arzt


90744 Fürth

Phone: 0911 -7580-1044
Fax: 0911-7580-1049
Mail: ed.htreuf-mukinilk@essorg.xilef

- Vorstand - Ärztlicher Direktor - Pflegedirektor - Personalleitung - Bereichsleitung Technik - Risikomanagement-Beauftragte (Stabstelle QRM) - Risikoexperten (ISB, DSB, FASI, KH-Hygieniker) - Betriebsarzt - CIRS-Teamleitung - Beschwerdemanager

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

Elektronisches QM-Portal Klinikum Fürth (19.07.2022)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Elektronisches QM-Portal Klinikum Fürth (30.04.2022)

RM05

Pain management

Elektronisches QM-Portal Klinikum Fürth (11.02.2022)

RM06

Fall prophylaxis

Elektronisches QM-Portal Klinikum Fürth (20.02.2020)

RM07

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

Elektronisches QM-Portal Klinikum Fürth (14.11.2021)

RM08

Regulated handling of custodial measures

Elektronisches QM-Portal Klinikum Fürth (28.01.2022)

RM09

Regulated handling of occurring malfunctions of devices

Elektronisches QM-Portal Klinikum Fürth (10.04.2022)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Pathologiebesprechungen
  • Palliativbesprechungen
  • Qualitätszirkel
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

Elektronisches QM-Portal Klinikum Fürth (12.02.2020)

RM15

Preoperative, complete presentation of necessary findings

Elektronisches QM-Portal Klinikum Fürth (04.03.2021)

RM16

Procedure to avoid procedural and patient mix-ups

Elektronisches QM-Portal Klinikum Fürth (10.01.2021)

RM17

Standards for recovery and postoperative care

Elektronisches QM-Portal Klinikum Fürth (16.10.2020)

RM18

Discharge management

Elektronisches QM-Portal Klinikum Fürth (30.03.2021)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

- Maßnahmen zur Verbesserung der Arzneimitteltherapiesicherheit

No. Explanation
IF01

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

As of: 16.11.2022

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 quartalsweise

Conference committee

Conference frequency: monatlich

No. Explanation
EF01

CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association, National Association of Statutory Health Insurance Doctors)

EF02

CIRS Berlin (Medical Association Berlin, German Medical Association, National Association of Statutory Health Insurance Doctors)

EF03

KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors)

EF08

CIRS Emergency Medicine (Department of Anaesthesia, Intensive Care Medicine and Emergency Medicine, Kempten Hospital)

EF10

CIRS of the German Society of Surgery (DGCH)

EF12

“Every mistake counts” (Institute for General Medicine Frankfurt)