To the hospital’s home page

Marien Hospital Papenburg Aschendorf gGmbH Standort Papenburg

Dealing with risks in patient care

Quality management

Responsible person

Verena Scholtyssek

Qualitätsmanagement Beauftragte

Hauptkanal rechts 74 - 75
26871 Papenburg

Phone: 04961 -93-1009
Mail: ed.grubnepap-latipsoh@kessytlohcs.anerev

Steering committee

Pflegedirektion, Geschäftsführung, Abteilungsleitungen

Conference frequency: monatlich

Risk management

Responsible person

Verena Scholtyssek

Qualitätsmanagement Beauftragte

Hauptkanal rechts 74-75
26871 Papenburg

Phone: 04961 -93-1009
Mail: ed.grubnepap-latipsoh@kessytlohcs.anerev

Steering committee

Anästhesie, Gastroenterologie, AEMP, ZNA, Pflegedienst, Kinder- und Jugendpsychiatrie, Hygiene, Qualitätsmanagement, Mitarbeitervertretung, Schnittstelle IT

Conference frequency: monatlich

Risk management instruments and measures

Instruments and measures

No.	Explanation
RM02	Regular further education and training measures
RM04	Clinical emergency management Notfallkonzept (30.06.2023)
RM05	Pain management Expertenstandard Schmerzmanagement in der Pflege (09.12.2022)
RM06	Fall prophylaxis Expertenstandard Sturzprophylaxe (15.11.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusprophylaxe in der Pflege (23.07.2021)
RM08	Regulated handling of custodial measures Fixierung (24.04.2023)
RM09	Regulated handling of occurring malfunctions of devices Meldeweg bei Vorkommissen (02.08.2021)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Mortalitäts- und Morbiditätskonferenzen Systemanalyse klinischer Zwischenfälle
RM12	Use of standardised information sheets
RM13	Application of standardised surgical check lists
RM16	Procedure to avoid procedural and patient mix-ups Markierung von Patienten/ Perioperative Sicherheitscheckliste (19.01.2023)
RM18	Discharge management Prozess Entlassung (02.12.2021)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Maßnahmenplanung nach Ursachenanalyse

No.	Explanation
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

No.

Explanation

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

Across all institutions

Conference committee

Conference frequency: bei Bedarf

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)