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CaritasKlinikum Saarbrücken Standort St. Theresia

Dealing with risks in patient care

Quality management

Responsible person

Dr.-Ing. Bettina Hahne

Leiterin Qualitätsmanagement

Rheinstraße 2
66113 Saarbrücken

Phone: 0681 -406-2898
Mail: ed.mukinilksatirac@enhah.b

Steering committee

Vertreter der Pflegedirektion (QM-Pflege), Vertreter des Ärztlichen Bereiches (Geriatrie), Mitarbeiter des Belegungsmanagements, Mitarbeiter der Abteilung Qualitätsmanagement, Mitarbeitervertretung

Conference frequency: monatlich

Risk management

Responsible person

Bettina Hahne

Leiterin Qualitätsmanagement

Rheinstraße 2
66113 Saarbrücken

Phone: 0681 -406-2898
Fax: 0681-406-1877
Mail: ed.mukinilksatirac@enhah.b

Steering committee

Um das Thema Risikomanagement in Verbindung mit CIRS im CaritasKlinikum zu etablieren, wurde eine Projektgruppe gebildet; ferner werden die Themen im QM-Steuerkreis besprochen.

Conference frequency: monatlich

Risk management instruments and measures

Instruments and measures

No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available elektronisches QM- Handbuch vorhanden (31.12.2022)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Bestandteil des elektronischen QM-Handbuches (31.12.2022)
RM05	Pain management Bestandteil des elektronischen QM-Handbuches (31.12.2022)
RM06	Fall prophylaxis Bestandteil des elektronischen QM-Handbuches (31.12.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Bestandteil des elektronischen QM-Handbuches (31.12.2022)
RM08	Regulated handling of custodial measures Bestandteil des elektronischen QM-Handbuches (31.12.2022)
RM09	Regulated handling of occurring malfunctions of devices Bestandteil des QM-Handbuches (31.12.2022)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Pathologiebesprechungen Palliativbesprechungen
RM12	Use of standardised information sheets
RM13	Application of standardised surgical check lists
RM16	Procedure to avoid procedural and patient mix-ups Bestandteil des elektronischen QM-Handbuches (31.12.2022)
RM17	Standards for recovery and postoperative care Bestandteil des elektronischen QM-Handbuches (31.12.2022)
RM18	Discharge management Bestandteil des elektronischen QM-Handbuches (31.12.2022)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Veränderungsmaßnahmen sind noch in der Umsetzung

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 15.06.2021
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

No.

Explanation

IF01

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

As of: 15.06.2021

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

Across all institutions

Conference committee

Conference frequency: monatlich

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)