Dealing with risks in patient care

Quality management

Anne Urban

Qualitätsmanagementbeauftragte

Heilstättenweg 1
27777 Ganderkesee

Phone: 04223 -71-208
Mail: ed.ohtro-munets@nabru

Ärztlicher Dienst, Pflegedienst, OP-Personal, Beschwerdemanagement, Qualitätsmanagement, Verwaltungsleitung, Physiotherapie, Öffentlichkeitsarbeit, IT

Conference frequency: jährlich

Risk management

Anne Urban

Risikomanagerin

Phone: 04223 -71-208
Fax: 04223-71-348
Mail: ed.ohtro-munets@nabru

Ärztlicher Dienst, Pflegedienst, OP-Personal, Beschwerdemanagement, Qualitätsmanagement, Verwaltungsleitung, Physiotherapie, Öffentlichkeitsarbeit, IT

Conference frequency: jährlich

Risk management instruments and measures

No. Explanation
RM01

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

Integriertes Managementsystem (01.01.2015)

RM02

Regular further education and training measures

RM04

Clinical emergency management

Integriertes Managementsystem (01.01.2015)

RM05

Pain management

Integriertes Managementsystem (01.01.2015)

RM06

Fall prophylaxis

Integriertes Managementsystem (01.01.2015)

RM07

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

Integriertes Managementsystem (01.01.2015)

RM09

Regulated handling of occurring malfunctions of devices

Integriertes Managementsystem (01.01.2015)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Mortalitäts- und Morbiditätskonferenzen
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

Integriertes Managementsystem (01.01.2015)

RM15

Preoperative, complete presentation of necessary findings

Integriertes Managementsystem (01.01.2015)

RM16

Procedure to avoid procedural and patient mix-ups

Integriertes Managementsystem (01.01.2015)

RM17

Standards for recovery and postoperative care

Integriertes Managementsystem (01.01.2015)

RM18

Discharge management

Integriertes Managementsystem (01.01.2015)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Monatliches CIRS-Sitzung

No. Explanation
IF01

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

As of: 01.01.2016

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: