Dealing with risks in patient care
Quality management
Walter Hellekamps
Qualitätsmanagementbeauftragter
Dr.-Frössel-Allee 1
37412 Herzberg am Harz
Phone:
05521
-866-50711
Mail:
ed.tiehdnuseg-soileh@spmakelleh.retlaw
Vertreter der Abteilungen
Conference frequency: bei Bedarf
Risk management
Stephan Matzath
Ärztlicher Direktor
Phone:
05521
-866-50420
Mail:
ed.tiehdnuseg-soileh@htaztam.nahpets
Ärzte und Pflegepersonal, Pflegedirektion
Conference frequency: bei Bedarf
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM05 |
Pain management Handlungsempfehlung Schmerzmanagement in der Pflege bei akuten und chronischen Schmerzen (01.09.2019) |
| RM06 |
Fall prophylaxis Beschluss der FG Pflege Sturzprophylaxe (01.02.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Beschluss der FG Pflege Dekubitusprophylaxe (01.11.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices Verfahrensstandard Umgang mit Produktproblemen (ZD Einkauf) (29.05.2015) |
| 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 Konzernregelung OP-Sicherheit (27.01.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings Konzernregelung OP-Sicherheit (27.01.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Konzernregelung OP-Sicherheit (27.01.2022) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Patientenidentifikationsbänder, Implementierung prä / post OP-Bögen, ZVK-Check Bogen, Transfusions-Check Bogen
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 23.03.2020 |
| IF02 |
Internal evaluation of the received reports taken bei Bedarf |
| IF03 |
Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken jährlich |
Conference committee
Conference frequency: bei Bedarf
| 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) |