Dealing with risks in patient care
Quality management
Dipl. Biol. Sabine Schröder
QMB und Leitbildbeauftragte
Schwachhauser Heerstraße 54
28209 Bremen
Phone:
0421
-347-1803
Mail:
ed.sjs@redeorhcss
Projektsteuerungsgruppe, Qualitätsmanagement - Team und Auditgruppe monatliche Treffen
Conference frequency: andere Frequenz
Risk management
Sabine Schröder
QMB und Leitbildbeauftragte
Schwachhauser Heerstraße 54
28209 Bremen
Phone:
0421
-347-1803
Mail:
ed.sjs@redeorhcss
Klinikrisikomanagementgruppe
Conference frequency: halbjährlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Organisationshandbuch SJS, Konzept 2024-10-11, Risiken Bereich Audit, Risiken Haus, VA Patientensicherheit (11.10.2024) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management KLÜ-AB-061 Notfallmanagement (12.12.2023) |
| RM05 |
Pain management Schmerzmanagement z.B. Stufenpläne Schmerzerkrankung (23.04.2023) |
| RM06 |
Fall prophylaxis Pflegeleitlinie Sturzprophylaxe (29.12.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusprophylaxe (29.12.2023) |
| RM08 |
Regulated handling of custodial measures KLÜ-AB-157 Verfahren freiheitsentziehender Maßnahmen Fixierung (15.10.2020) |
| RM09 |
Regulated handling of occurring malfunctions of devices Verfahrensanweisung Umsetzung der Medizinproduktebetreiberverordnung (29.08.2022) |
| 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 Konzept Risikomanagement (11.10.2024) |
| RM15 |
Preoperative, complete presentation of necessary findings Konzept Risikomanagement (11.10.2024) |
| RM16 |
Procedure to avoid procedural and patient mix-ups WHO Liste Patientensicherheit differenziert für Chirurgie/Gynäkologie, HNO und Augenklinik (28.07.2022) |
| RM17 |
Standards for recovery and postoperative care Postoperative Überwachung nach Anästhesieverfahren, Perioperative Aufnahmekriterien für die ITS (26.03.2024) |
| RM18 |
Discharge management Entlassmanagement Ordner diverse Dokumente (11.03.2022) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Einführung von Patientenarmbändern, Führung einer WHO-Liste Patientensicherheit, Schulungsmaßnahmen usw.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 17.10.2023 |
| 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: monatlich
| No. | Explanation |
|---|---|
|
Other |
|
| EF06 |
CIRS NRW (North Rhine and Westphalia-Lippe Medical Associations, North Rhine-Westphalia Hospital Association, North Rhine and Westphalia-Lippe Associations of Statutory Health Insurance Physicians, German Medical Association) |