Dealing with risks in patient care
Quality management
Lara Lehmann
Qualitätsmanagement
Niedersachsendamm 72-74
28201 Bremen
Phone:
0421
-8778-146
Mail:
ed.kinilk-dnalor@nnamhell
Geschäftsleitung, Verwaltungsleitung, Pflegedirektion, Chefärzte, QM
Conference frequency: quartalsweise
Risk management
Lara Lehmann
Qualitätsmanagement
28201 Bremen
Phone:
0421
-8778-146
Fax: 0421-8778-267
Mail:
ed.kinilk-dnalor@nnamhell
Geschäftsleitung, Verwaltungsleitung, Pflegedirektion, Chefärzte, 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 (13.05.2025) |
| 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 (06.11.2024) |
| RM06 |
Fall prophylaxis Angepasster Expertenstandard Sturzprophylaxe in der Pflege (10.06.2025) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) angepasster Expertenstandard Dekubitusprophylaxe (10.06.2025) |
| RM08 |
Regulated handling of custodial measures Dienstanweisung zur Fixierung von Patienten und mitgeltende Unterlagen (28.02.2025) |
| RM09 |
Regulated handling of occurring malfunctions of devices Handbuch: Organisationshandbuch MPBetreibV und zugehörige Dokumente (21.10.2024) |
| 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 Nachbehandlungsschemata nach Prozeduren, Manual Akutschmerztherapie (06.11.2024) |
| RM18 |
Discharge management Standard zur Entlassungsplanung (11.07.2024) |
Fault reporting systems
Conference committee
Conference frequency: andere Frequenz
Measures
Vermehrte Schulung und Einweisung der Mitarbeitenden in den Umgang mit AED Geräten, um in Notsituationen einen höheren Grad von Vertrautheit mit dem Gerät zu haben.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 04.04.2024 |
| 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) |