Dealing with risks in patient care
Quality management
Frau Claudia-Christine Szulfer-Pollak, MHM
QMB
Wallinghausener Str. 8 - 12 8 - 12
26603 Aurich
Phone:
04941
-94-1140
Mail:
ed.k-e-u@kallop-refluzs.enitsirhc-aidualc
Conference frequency:
Risk management
Conference frequency:
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Dok.-Nr. 15435 Algorithmus Notfallmanagement (22.11.2023) |
| RM05 |
Pain management Dok.-Nr. 20566 Handbuch Schmerztherapie (22.11.2023) |
| RM06 |
Fall prophylaxis Dok.-Nr. 22977 Sturzprophylaxe (26.01.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dok,.Nr. 24921 Dekubitusprophylaxe (22.07.2023) |
| RM08 |
Regulated handling of custodial measures Anordnung von freiheitsentziehenden Maßnahmen inkl. Dokumentation und Einrichtung eines Betreuungs- und Fixierungsbeschlusses (im KIS hinterlegt) (01.07.2019) |
| RM09 |
Regulated handling of occurring malfunctions of devices VA PDL 02 Einweisung Medizinprodukte (01.09.2020) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM13 |
Application of standardised surgical check lists |
| RM16 |
Procedure to avoid procedural and patient mix-ups Dok.-Nr. 24692 CL Patientensicherheit (06.06.2023) |
| RM17 |
Standards for recovery and postoperative care Dok.-Nr. 15479 AWR-Pflege und Überwachung, Dok.-Nr. 15491 Komplikationen im AWR (10.11.2023) |
| RM18 |
Discharge management Leitfaden Entlassmanagement (01.09.2017) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Durch größtmögliche Umsetzung der vom CIRS-Team vorgeschlagenen Massnahmen wie z.B. durchgängige Vorhaltung von Bettgittern oder auch Verfahrensanweisungen zur Patienenidentifikation mittels Barcode-Armbändchen bei Laborabnahmen in Patientenzimmern wurden in vielen Bereichen Verbesserungen erreicht.
| No. | Explanation |
|---|---|
| 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 |
Conference committee
Conference frequency:
| 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) |
| EF13 |
DokuPIK (Documentation of Pharmaceutical Interventions in Hospitals at the Federal Association of German Hospital Pharmacists (ADKA) |