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Krankenhaus Landshut-Achdorf

Dealing with risks in patient care

Quality management

Responsible person

Carolin Nowak

Leitung Qualitätsmanagement

Achdorfer Weg 3
84036 Landshut

Phone: 0871 -404-0
Mail: ed.demukal@mq

Steering committee

Risikogremium: Geschäftsführung, Chefärzte, Leitende Oberärzte, Pflegedienstleitung, Qualitätsmanagementbeauftragter, Abteilungsleiter der Verwaltung, Personalrat

Conference frequency: quartalsweise

Risk management

Responsible person

Carolin Nowak

Risikomanagementbeauftragte

Achdorfer Weg 3
84036 Landshut

Phone: 0871 -404-0
Fax: 0871-404-1652
Mail: ed.demukal@tnemeganamokisir

Steering committee

Risikoteam: Pflegedirektor, Qualitätsmanagement, Risikomanagementbeauftragter Risikogremium: Risikoteam, Ärztlicher Direktor, Geschäftsführung, Vertreter anderer Bereiche je nach CIRS-Fall

Conference frequency: quartalsweise

Risk management instruments and measures

Instruments and measures

No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikomanagementhandbuch (03.06.2022)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Risikomanagementhandbuch (03.06.2022)
RM05	Pain management Schmerzmanagement in der Pflege (05.07.2022)
RM06	Fall prophylaxis Konzepte werden von den aktuell gültigen Versionen der Expertenstandards Pflege (DNQP) abgleitet und in der Prozessstruktur Pflegedienst umgesetzt. (25.10.2021)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Konzepte werden von den aktuell gültigen Versionen der Expertenstandards Pflege (DNQP) abgleitet und in der Prozessstruktur Pflegedienst umgesetzt. (25.10.2021)
RM09	Regulated handling of occurring malfunctions of devices Prozess "Technischer Dienst Landshut / Defekte Geräte" (06.07.2021)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Palliativbesprechungen
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-Statut für das Krankenhaus Landshut-Achdorf (18.11.2022)
RM15	Preoperative, complete presentation of necessary findings OP-Statut für das Krankenhaus Landshut-Achdorf (18.11.2022)
RM16	Procedure to avoid procedural and patient mix-ups Sicherheits-checkliste für operative Eingriffe (13.05.2022)
RM17	Standards for recovery and postoperative care Postoperative Überwachung im Aufwachraum (10.11.2020)
RM18	Discharge management Entlassmanagement (23.06.2023)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Aktive Teilnahme am Welttag Patientensicherheit, Aktive Schulungen der MA zum Thema Patientensicherheit und Absetzen von CIRS Meldungen

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 03.06.2022
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 bei Bedarf

No.

Explanation

IF01

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

As of: 03.06.2022

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 bei Bedarf

Across all institutions

Conference committee

Conference frequency: monatlich

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)