Dealing with risks in patient care
Quality management
Annett Buck
Leitung Qualitätsmanagement
Niedersachsendamm 72-74
28201 Bremen
Phone:
0421
-8778-146
Mail:
ed.kinilk-dnalor@kcuba
Geschäftsleitung, Verwaltung, Pflege, Ärzte, QM
Conference frequency: quartalsweise
Risk management
Annett Buck
Leitung Qualitätsmanagement
28201 Bremen
Phone:
0421
-8778-146
Fax: 0421-8778-267
Mail:
ed.kinilk-dnalor@kcuba
Geschäftsleitung, Verwaltung, Pflege, Ärzte, QM
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Managementbewertung (17.05.2024) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Konzept Notfallmanagement, Fortbildungen zum Notfallmanagement, M&M Konferenzen, Prozessbeschreibung (15.11.2023) |
| RM05 |
Pain management Manual Schmerzmanagement, Leitlinie Schmerzmanagement und zugehörige Dokumente (01.11.2023) |
| RM06 |
Fall prophylaxis hausinterner Standard Sturzprophylaxe (24.03.2024) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Pflegestandard Dekubitusprophylaxe in Anlehnung an den Expertenstandard des Deutschen Netzwerk für Qualitätsentwicklung in der Pflege (20.05.2023) |
| RM08 |
Regulated handling of custodial measures Dienstanweisung zur Fixierung von Patienten und mitgeltende Unterlagen (10.02.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Handbuch: Organisationshandbuch MPBetreibV und zugehörige Dokumente (14.09.2022) |
| 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 Risikoscreenings OP Verfahren (01.07.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings Prozessbeschreibung: Einschleusung in den ZOP (26.04.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Umsetzung der Empfehlung vom Aktionsbündnis für Patientensicherheit: Handlungsempfehlungen zur Vermeidung von Eingriffsverwechslungen in der Chirurgie (12.06.2024) |
| RM17 |
Standards for recovery and postoperative care Manual Akutschmerztherapie, Nachbehandlungsschemata nach Prozeduren (01.11.2023) |
| RM18 |
Discharge management Prozessdarstellung Entlassungsmanagement (22.09.2021) |
Fault reporting systems
Conference committee
Conference frequency: wöchentlich
Measures
ein Hinweisschild zum Standort des EKG-Gerätes wurde angebracht, um das Auffinden dieses in einer Notfallsituation für alle zu vereinfachen
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 12.07.2022 |
| IF02 |
Internal evaluation of the received reports taken quartalsweise |
| IF03 |
Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken monatlich |
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) |
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |