Dealing with risks in patient care

Quality management

Holger Schlichter

Qualitätsmanagementbeauftragter

Kapuziner Straße 4
66740 Saarlouis

Phone: 06831 -16-1008
Mail: ed.suahneiram@rethcilhcs.regloh

Kaufmännische Direktion, Pflegedirektion, Oberarzt, Qualitätsmanagement, Mitarbeitervertretung

Conference frequency: halbjährlich

Risk management

Michael Kunz

Ärztlicher Direktor

Kapuziner Straße 4
66740 Saarlouis

Phone: 06831 -16-1801
Fax: 06831-16-1807
Mail: ed.suahneiram@znuk.leahcim

Stephan Kremers

Ärztlicher Direktor

Kapuziner Straße 4
66740 Saarlouis

Phone: 06831 -16-1560
Fax: 06831-16-1567
Mail: ed.suahneiram@sremerk.nahpets

Ärztlicher Direktor, stellvertretender ärztlicher Direktor, Pflegedirektor, Oberarzt Anästhesie, Qualitätsmanagementbeauftragte

Conference frequency: halbjährlich

Risk management instruments and measures

No. Explanation
RM01

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

QM-Handbuch in elektronischer Form (01.01.2022)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

QM-Handbuch in elektronischer Form (01.01.2022)

RM05

Pain management

QM-Handbuch in elektronischer Form (01.01.2022)

RM06

Fall prophylaxis

QM-Handbuch in elektronischer Form (01.01.2022)

RM07

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

QM-Handbuch in elektronischer Form (01.01.2022)

RM08

Regulated handling of custodial measures

QM-Handbuch in elektronischer Form (01.01.2022)

RM09

Regulated handling of occurring malfunctions of devices

QM-Handbuch in elektronischer Form (01.01.2022)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Palliativbesprechungen
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

QM-Handbuch in elektronischer Form (01.01.2022)

RM15

Preoperative, complete presentation of necessary findings

QM-Handbuch in elektronischer Form (01.01.2022)

RM16

Procedure to avoid procedural and patient mix-ups

QM-Handbuch in elektronischer Form (01.01.2022)

RM17

Standards for recovery and postoperative care

QM-Handbuch in elektronischer Form (01.01.2022)

RM18

Discharge management

QM-Handbuch in elektronischer Form (01.01.2022)

Fault reporting systems

Conference committee

Conference frequency: bei Bedarf

Measures

Antibiotic Stewardship

No. Explanation
IF01

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

As of: 01.01.2022

IF02

Internal evaluation of the received reports

taken bei Bedarf

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: bei Bedarf

No. Explanation

Other