Dealing with risks in patient care
Quality management
Claudia Schubert
Geschäftsbereichsleitung Qualitäts- und strukturelles Medizinmanagement
Eichertstraße 3
73035 Göppingen
Phone:
07161
-64-6300
Mail:
ed.k-fa@trebuhcs.aidualc
Geschäftsführung, Qualitätsmanagement, Pflegedirektion, ausgewählte Chefärzte, Finanzbuchhaltung, Medizincontrolling, OP-Management, Betriebsärztlicher Dienst, EDV-Abteilung
Conference frequency: wöchentlich
Risk management
Claudia Schubert
Geschäftsbereichsleitung Qualitäts- und strukturelles Medizinmanagement
Phone:
07161
-64-6300
Mail:
ed.k-fa@trebuhcs.aidualc
Risikoteam aus Geschäftsführung, Qualitätsmanagement, Mitarbeiter Pflege, ärztliche Mitarbeiter
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Dokumentierte Informationen in BITqms (D4120 & D14793) (01.04.2025) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Dokumentierte Informationen in BITqms (D4120 & D14793) (01.04.2025) |
| RM05 |
Pain management Dokumentierte Informationen in BITqms (D4120 & D14793) (01.04.2025) |
| RM06 |
Fall prophylaxis Dokumentierte Informationen in BITqms (D4120 & D14793) (01.04.2025) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dokumentierte Informationen in BITqms (D4120 & D14793) (01.04.2025) |
| RM08 |
Regulated handling of custodial measures Dokumentierte Informationen in BITqms (D4120 & D14793) (01.04.2025) |
| RM09 |
Regulated handling of occurring malfunctions of devices Dokumentierte Informationen in BITqms (D4120 & D14793) (01.04.2025) |
| 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 Dokumentierte Informationen in BITqms (D4120 & D14793) (01.04.2025) |
| RM15 |
Preoperative, complete presentation of necessary findings Dokumentierte Informationen in BITqms (D4120 & D14793) (01.04.2025) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Dokumentierte Informationen in BITqms (D4120 & D14793) (01.04.2025) |
| RM17 |
Standards for recovery and postoperative care Dokumentierte Informationen in BITqms (D4120 & D14793) (01.04.2025) |
| RM18 |
Discharge management Dokumentierte Informationen in BITqms (D4120 & D14793) (01.04.2025) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Patientenidentifikationsarmband, OP-Sicherheitscheckliste (WHO), Hygienevisiten, Risikoadaptierte Screenings, Maßnahmen zur Arbeitssicherheit, interne Audits (QM), Verfahrensanweisungen zur Patientensicherheit, M&M-Konferenzen, Elektronische Medikamentenanordnung, Strukturierte Schadensaufarbeitung, Etablierung von Red Rules, WLAN-Telefonie Teilnahme an CIRS
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 28.07.2025 |
| IF02 |
Internal evaluation of the received reports taken jährlich |
| 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: quartalsweise
| No. | Explanation |
|---|---|
| EF01 |
CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association) |