Dealing with risks in patient care

Quality management

Manja Mohr

Standortübergreifende Leitung Qualitäts-, Risiko- & Prozessmanagement

Heinz-Meise-Straße 100
36199 Rotenburg a. d. Fulda

Phone: 06623 -88-6221
Mail: ed.grubnetor-zkh@bmq

Geschäftsführung / Ärztlicher Dienst / Pflegedienst / Therapeutischer Dienst / Verwaltung

Conference frequency: quartalsweise

Risk management

Manja Mohr

Standortübergreifende Leitung Qualitäts-, Risiko- & Prozessmanagement

Phone: 06623 -88-6221
Fax: 06623-88-6262
Mail: ed.grubnetor-zkh@bmq

Geschäftsführung / Ärztlicher Dienst / Pflegedienst / Therapeutischer Dienst / Verwaltung

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

Risikopolitik (08.11.2023)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Risikopolitik (08.11.2023)

RM06

Fall prophylaxis

Risikopolitik (08.11.2023)

RM07

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

Risikopolitik (08.11.2023)

RM08

Regulated handling of custodial measures

Risikopolitik (08.11.2023)

RM09

Regulated handling of occurring malfunctions of devices

Risikopolitik (08.11.2023)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Mortalitäts- und Morbiditätskonferenzen
  • Tumorkonferenzen
  • Pathologiebesprechungen
  • Qualitätszirkel
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 (03.05.2020)

RM15

Preoperative, complete presentation of necessary findings

OP-Checkliste (03.05.2020)

RM17

Standards for recovery and postoperative care

Risikopolitik (08.11.2023)

RM18

Discharge management

Risikopolitik (08.11.2023)

Fault reporting systems

Conference committee

Conference frequency: andere Frequenz

Measures

Mitarbeiterschulung im Umgang mit Laborproben

No. Explanation
IF01

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

As of: 27.07.2021

IF02

Internal evaluation of the received reports

taken jährlich

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: quartalsweise

No. Explanation
EF03

KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association)