Dealing with risks in patient care
Quality management
Iris Schütze
Qualitätsmanagement
Alphonsstraße 14
22043 Hamburg
Phone:
040
-181883-2232
Mail:
moc.soipelksa@kebsdnaw.tnemeganamsteatilauq
Geschäftsführende Direktorin, Ärztlicher Direktor, Pflegedirektor, Klinikmanagerin, CIRS- & Beschwerdemanagerin, Qualitätsmanagerin
Conference frequency: monatlich
Risk management
Iris Schütze
Qualitätsmanagement
Alphonsstraße 14
22043 Hamburg
Phone:
040
-181883-2232
Fax: 040-181883-2401
Mail:
moc.soipelksa@kebsdnaw.tnemeganamsteatilauq
Geschäftsführende Direktorin, Ärztlicher Direktor, Pflegedirektor, Klinikmanagerin, CIRS- & Beschwerdemanagerin, Qualitätsmanagerin
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Konzept klinisches Risikomanagement (23.03.2023) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Reanimationsalarm (11.12.2023) |
| RM05 |
Pain management Konzept Akutschmerz (13.12.2021) |
| RM06 |
Fall prophylaxis Leitlinie Expertenstandard Sturzprophylaxe; VA Sturzmanagement (02.07.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Leitlinie Expertenstandard Dekubitusprophylaxe (30.09.2022) |
| RM08 |
Regulated handling of custodial measures VA Freiheitsentziehende Maßnahmen (21.07.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices Organisationshandbuch Medizinproduktegesetz (15.09.2023) |
| 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 Bestandteil der VA Asklepios Sicherheits-Checkliste OP (24.02.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings Bestandteil der VA Asklepios Sicherheits-Checkliste OP (24.02.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups VA Vermeidung einer Eingriffsverwechslung; VA Sichere Patientenidentifikation (15.07.2024) |
| RM17 |
Standards for recovery and postoperative care SOP Patientenversorgung im Aufwachraum (29.03.2022) |
| RM18 |
Discharge management VA Entlassmanagement (30.05.2023) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Im Jahr 2023 wurden 58 Maßnahmen aufgrund von CIRS Meldungen umgesetzt.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 14.03.2024 |
| 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 bei Bedarf |
Conference committee
Conference frequency: monatlich
| No. | Explanation |
|---|---|
|
Other |
|
| EF14 |
CIRS Health Care |