Dealing with risks in patient care
Quality management
Geschäftsführung, Pflegedirektion, Kaufmännische Leitung, QMB
Conference frequency: monatlich
Risk management
Anja Preiss
QMB
Eppenreuther Str. 9
95032 Hof
Phone:
09281
-98-3322
Fax: 09281-98-2627
Mail:
ed.anas@ssierp.ajna
Geschäftsführung, Pflegedirektion, Kaufmännische Leitung, QMB
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM System Sana Klinikum Hof, Sana Management Handbuch (14.11.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Verfahrensanweisung Medizinisches Notfallmanagement, Sana Management Handbuch (26.04.2022) |
| RM05 |
Pain management Arbeitsanweisungen Allgemeine Schmerztherapie (19.08.2020) |
| RM06 |
Fall prophylaxis Verfahrensanweisung Sturzprophylaxe und Sturzerfassung (01.07.2020) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Verfahrensanweisung Dekubitusprophylaxe, Sana Management Handbuch (23.08.2022) |
| RM08 |
Regulated handling of custodial measures Verfahrensanweisung Freiheitsentziehende Maßnahmen - FEM, Sana Management Handbuch (23.08.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices QM System Sana Klinikum Hof; Samba Handbuch, Sana Management Handbuch (14.11.2022) |
| 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 Verfahrensanweisung und Formular Einsatz OP-Sicherheits-Checkliste, Sana Management Handbuch (17.11.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings Verfahrensanweisung und Formular Einsatz OP-Sicherheits-Checkliste, Sana Management Handbuch (17.11.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Arbeitsanweisung Patientenidentifikationsband und Arbeitsanweisung Patientenidentifikationsband Kinderklinik Kreißsaal, Sana Management Handbuch (09.05.2022) |
| RM17 |
Standards for recovery and postoperative care Verfahrensanweisung Aufnahme und Versorgung postoperativer Patienten, Sana Management Handbuch (28.10.2019) |
| RM18 |
Discharge management Verfahrensanweisung Entlassmanagement (23.08.2021) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
OP-Sicherheits-Checkliste WHO, Patientenidentifikationsband, Morbiditäts- und Mortalitätskonferenz, Dekubitusprävention, Sturzprävention, Simulationstraining
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.11.2022 |
| 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: monatlich
| No. | Explanation |
|---|---|
|
Other |