Dealing with risks in patient care
Quality management
Herr Michael Schmitt
Geschäftsführer
Lange-Feld-Straße 31
30559 Hannover
Phone:
0511
-950-4000
Mail:
ed.suahneknarkznezniv@esseH.aleahciM
Monatlicher Austausch zwischen Geschäftsführung und Qualitäts- und Risikomanagement. Im Rahmen der Zertifizierungen erfolgt ein regelmäßiger Austausch mit den beteiligten Bereichen.
Conference frequency: monatlich
Risk management
Michael Schmitt
Geschäftsführer
30559 Hannover
Phone:
0511
-950-4000
Fax: 0511-950-4178
Mail:
ed.suahneknarkznezniv@esseH.aleahciM
Im Rahmen des Integrierten Risikomanagements über den EVV-Verbund.
Conference frequency: andere Frequenz
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikorichtlinie Vinzenzkrankenhaus Hannover GmbH (26.04.2019) |
| RM02 |
Regular further education and training measures |
| RM05 |
Pain management Es liegen für die jeweiligen Fachabteilungen SOPs zum Schmerzmanagement vor, beispielsweise: SOP - Standard Perioperative Schmerztherapie Allgemeinchirurgie (19.12.2024) |
| RM06 |
Fall prophylaxis Pflegestandard Sturzprophylaxe (05.09.2024) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Pflegestandard Dekubitusprophylaxe (08.11.2023) |
| RM08 |
Regulated handling of custodial measures Prozessbeschreibung Umgang mit Fixierung (05.09.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Begleitheft für Beauftragte MedizinProdukteBetreibV (04.03.2025) |
| 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 OP-Statut (20.06.2025) |
| RM15 |
Preoperative, complete presentation of necessary findings OP-Statut (20.06.2025) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Patientenidentifikation bei Medikation, Transport, Diagnostik und Behandlung (30.05.2025) |
| RM17 |
Standards for recovery and postoperative care SOP – Standardversorgung Aufwachraum (27.05.2024) |
| RM18 |
Discharge management Entlassungsstandard (06.06.2025) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Anpassung von Prozessen und Standards, Anschaffung erforderlicher Materialien
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 21.07.2025 |
| 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 bei Bedarf |
Conference committee
Conference frequency: bei Bedarf
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |