Konstanze Gall
Qualitäts- und Risikomanagement
                    Paul-Gerhardt-Straße 42-45
                    06886 Lutherstadt Wittenberg
                
             Phone:
            03491
                -50-2877
                            
                 Mail:
                ed.dsj@tfitsgp.tnemeganamsteatilauq
                    
Direktorium mit Vertretung aller Bereiche des Krankenhauses
Conference frequency: andere Frequenz
Konstanze Gall
Qualitäts- und Risikomanagement
                    Paul-Gerhardt-Straße 42-45
                    06886 Lutherstadt Wittenberg
                
             Phone:
            03491
                -50-2877
            
                            
                 Mail:
                ed.dsj@tfitsgp.tnemeganamsteatilauq
                    
Direktorium mit Vertretung aller Bereiche des Krankenhauses
Conference frequency: andere Frequenz
| No. | Explanation | 
|---|---|
| RM01 | 
														 Comprehensive quality and/or risk management documentation (QM/RM documentation) is available VA "Strategie Klinisches Risikomanagement" (06.08.2020)  | 
												
| RM02 | 
														 Regular further education and training measures  | 
												
| RM03 | 
														 Employee surveys  | 
												
| RM04 | 
														 Clinical emergency management VA "Medizinisches Notfallmanagement" (23.03.2021)  | 
												
| RM05 | 
														 Pain management VA Schmerzerfassung und -dokumentation (19.09.2023)  | 
												
| RM06 | 
														 Fall prophylaxis VA "Sturzprophylaxe" (17.02.2022)  | 
												
| RM07 | 
														 Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) VA "Dekubitusprophylaxe" (05.09.2023)  | 
												
| RM08 | 
														 Regulated handling of custodial measures VA "Umgang mit freiheitsentziehenden Maßnahmen" (18.12.2019)  | 
												
| RM09 | 
														 Regulated handling of occurring malfunctions of devices Dienstanweisung "Umgang mit Medizinprodukten" (21.12.2021)  | 
												
| 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 (24.07.2020)  | 
												
| RM15 | 
														 Preoperative, complete presentation of necessary findings OP-Checkliste (24.07.2020)  | 
												
| RM16 | 
														 Procedure to avoid procedural and patient mix-ups OP-Checkliste (24.07.2020)  | 
												
| RM17 | 
														 Standards for recovery and postoperative care VA "Postoperatives Komplikationsmanagement" (13.09.2016)  | 
												
| RM18 | 
														 Discharge management VA "Entlassungsmanagement" (02.10.2018)  | 
												
Conference frequency: monatlich
Kontinuierliche Verbesserung sicherheitsrelevanter Prozesse
| No. | Explanation | 
|---|---|
| IF01 | 
														 Documentation and procedural instructions for handling the error reporting system are available As of: 28.01.2021  | 
												
| 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 bei Bedarf  | 
												
Conference frequency: monatlich
| No. | Explanation | 
|---|---|
| 
															 Other  |