Dealing with risks in patient care

Quality management

Swenja Roth

Qualitätsmanagement

Schwabenröder Straße 81
36304 Alsfeld

Phone: 06631 -987391-
Mail: ed.dlefsla-hkk@htor.s

QM-Lenkungsteam: Geschäftsleitung, Betriebsrat, Qualitätsmanagement, Ärzte, Pflege, Hygiene, Funktionsdienste und Arbeitssicherheit

Conference frequency: monatlich

Risk management

Swenja Roth

Qualitätsmanagement

Phone: 06631 -987391-
Mail: ed.dlefsla-hkk@htor.s

QM-Lenkungsteam: Geschäftsleitung, Betriebsrat, Qualitätsmanagement, Ärzte, Pflege, Hygiene, Funktionsdienste und Arbeitssicherheit

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

Comprehensive quality and/or risk management documentation (QM/RM documentation) is available

QM-Handbuch (07.04.2022)

RM02

Regular further education and training measures

RM04

Clinical emergency management

QM-Handbuch (07.04.2022)

RM05

Pain management

QM-Handbuch (07.04.2022)

RM06

Fall prophylaxis

QM-Handbuch (07.04.2022)

RM07

Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”)

QM-Handbuch (07.04.2022)

RM08

Regulated handling of custodial measures

QM-Handbuch (07.04.2022)

RM09

Regulated handling of occurring malfunctions of devices

QM-Handbuch Medicalpart-externer Dienstleister (01.11.2018)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Palliativbesprechungen
  • Pathologiebesprechungen
  • interdiziplinäre Bauchstation
  • Leitungskonferenz
  • Fracture Unit
RM12

Use of standardised information sheets

RM13

Application of standardised surgical check lists

RM16

Procedure to avoid procedural and patient mix-ups

QM-Handbuch (07.04.2022)

RM17

Standards for recovery and postoperative care

Aufnahme, Überwachung und Entlassung aus dem AWR (10.06.2022)

RM18

Discharge management

QM-Handbuch (07.04.2022)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Einführung der übergreifenden Patientenakte, SOP Akuttherapie Sepsis inkl. Checkliste

No. Explanation
IF01

Documentation and procedural instructions for handling the error reporting system are available

As of: 11.08.2022

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 halbjährlich

Conference committee

Conference frequency: