Dealing with risks in patient care

Quality management

Dipl. Pflegewirtin (FH), QMB, QMA Gabriele Reichel

QMB

Gabriel-von-Seidl-Str. 81
67550 Worms

Phone: 06241 -501-4406
Mail: ed.smrow-mukinilk@lehcier.eleirbag

Alle zertifizierten Zentren, GF

Conference frequency: quartalsweise

Risk management

Gabriele Reichel

QMB

Gabriel-von-Seidl-Str. 81
67550 Worms

Phone: 06241 -501-4406
Fax: 06241-501-3099
Mail: ed.smrow-mukinilk@lehcier.eleirbag

Geschäftsführung, ISB, Projektmanagement, Qualitätsmanagement, Mitarbeiter der Fachabteilungen, weitere Mitarbeiter nach Bedarf

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

Abteilungsübergreifende Risikomatrix (30.06.2021)

RM02

Regular further education and training measures

RM04

Clinical emergency management

Schockraum-AG, Traumanetzwerk, Standards und Verfahrensanweisungen (30.06.2021)

RM05

Pain management

Standards und Verfahrensanweisungen (30.06.2021)

RM06

Fall prophylaxis

Standardrichtlinie (01.09.2021)

RM07

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

Standardrichtlinie (01.09.2022)

RM08

Regulated handling of custodial measures

Dienstanweisung (01.08.2022)

RM09

Regulated handling of occurring malfunctions of devices

Organisationshandbuch zum Medizinproduktemanagement (30.01.2020)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • 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

OP-Checkliste und Team Time Out (01.02.2019)

RM15

Preoperative, complete presentation of necessary findings

OP-Checkliste und Team Time Out, Tumorbord (30.06.2021)

RM16

Procedure to avoid procedural and patient mix-ups

OP-Checkliste und Team Time Out (01.02.2019)

RM17

Standards for recovery and postoperative care

Standards und verfahrensanweisungen (30.06.2021)

RM18

Discharge management

Entlassungsmanagement und Pflege- und Sozialberatung (01.09.2021)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

OP-Checkliste und Herzkatheter-Checkliste zur Patientensicherheit, Patientenarmbänder, Standards und Verfahrensanweisungen, diverse Checklisten

No. Explanation
IF01

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

As of: 15.05.2022

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: quartalsweise

No. Explanation
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)