Dealing with risks in patient care
Quality management
Dr. Hans-Henning Nölcke
Leitung Qualitätsmanagement
Am Krankenhaus 1
21614 Buxtehude
Phone:
04141
-97-1686
Mail:
ed.nekinilkeble@ekcleoN.gninneH
Geschäftsführung Betriebsleiter Ärztliche Direktoren Pflegedirektion Bereichsleiter Qualitätsmanagement
Conference frequency: halbjährlich
Risk management
Michael Albers
Sicherheits- und Risikomanager
Am Krankenhaus 1
21614 Buxtehude
Phone:
04141
-97-1078
Fax: 04141-97-1084
Mail:
ed.nekinilkeble@srebla.leahcim
Chefarztkonferenz
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015) |
| RM05 |
Pain management Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015) |
| RM06 |
Fall prophylaxis Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015) |
| RM08 |
Regulated handling of custodial measures Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015) |
| RM09 |
Regulated handling of occurring malfunctions of devices Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| 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 Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015) |
| RM15 |
Preoperative, complete presentation of necessary findings Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015) |
| RM17 |
Standards for recovery and postoperative care Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015) |
| RM18 |
Discharge management Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Pflichtfortbildungen für Ärzte und Pflege
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 02.02.2015 |
| IF02 |
Internal evaluation of the received reports taken quartalsweise |
| 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: halbjährlich
| 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) |