Dealing with risks in patient care
Quality management
Kristin Gottschalk
Qualitätsbeauftragte/QMB
Albertplatz 1
08261 Schöneck
Phone:
037423
-79-2502
Mail:
ed.dkp@klahcsttog.nitsirk
Die Treffen finden im Rahmen der Leitungssitzung (Klinikgeschäftsführer, Ärztlicher Leiter, Pflegedienstleiter, Chefärzte/Leiter der medizinischen Fachbereiche, Qualitätsbeauftragter) statt.
Conference frequency: monatlich
Risk management
Susanne Blinn
Leitung Zentraler Dienst Qualität
Albertplatz 1
08261 Schöneck
Phone:
0541
-6692-0
Mail:
ed.dkp@nnilb.ennasus
Die Treffen finden im Rahmen der Leitungssitzung (Klinikgeschäftsführer, Ärztlicher Leiter, Pflegedienstleiter, Chefärzte/Leiter der medizinischen Fachbereiche, Qualitätsbeauftragter) statt.
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 (16.01.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management SOP Notfallmanagement (06.07.2022) |
| RM05 |
Pain management SOP Schmerzmanagement (02.05.2022) |
| RM06 |
Fall prophylaxis Pflegestandard zur Sturzprophylaxe (12.07.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Pflegestandard zur Dekubitusprophylaxe und -therapie (12.07.2022) |
| RM08 |
Regulated handling of custodial measures SOP Fixierung, Fixierungsantrag, Fixierungsprotokoll (10.06.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices SOP Betrieb und Anwendung von Medizinprodukten (10.06.2022) |
| 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 OP-Checkliste, Team-time-out (27.04.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings im Rahmen der OP-Vorbereitung und täglichen Fallbesprechungen, OP-Checkliste (27.04.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Nutzung Patientenarmband, im Rahmen der OP-Vorbereitung mit der OP-Checkliste (27.04.2022) |
| RM17 |
Standards for recovery and postoperative care Pflegestandard zur postoperativen Überwachung (17.06.2022) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
monatliches Treffen des CIRS-Auswerterteams zur Fallanalyse/-besprechung
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 04.02.2021 |
| 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 jährlich |
Conference committee
Conference frequency: monatlich
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors) |