Dealing with risks in patient care
Quality management
Doris Achtert
Leitung Int. Organisation / Qualitätsmanagement
Pfarrer-Guggetzer-Straße 3
85560 Ebersberg
Phone:
08092
-82-2606
Mail:
ed.ebe-kinilk@sq
Qualitätskommission (1/2-jährlich), Klinikrat (monatlich), Strategietagungen (mind. 2x/Jahr)
Conference frequency: halbjährlich
Risk management
Marco Heinz
Risikokoordinator
Pfarrer-Guggetzer-Straße 3
85560 Ebersberg
Phone:
08092
-82-2551
Fax: 08092-82-2226
Mail:
ed.ebe-kinilk@znieh.ocram
Geschäftsführer, Risikokoordinator, Vorsitz CIRS AG, QM, Int. Org., Int. Koordinator Arbeitssicherheit, Betriebsratsvorsitzender, Ärztlicher Direktor, Ltg. Hygiene, Datenschutzkoordinator, Vorsitz Arzneimittelkommission, Pflegedirektor, QMB
Conference frequency: halbjährlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Klinisches Risikomanagementkonzept (10.07.2025) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Alarmplan Medizinischer Notfall (07.04.2025) |
| RM05 |
Pain management A 18 Schmerzmanagement (01.03.2024) |
| RM06 |
Fall prophylaxis A 14 Sturzprophylaxe (25.04.2025) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) A1 Dekubitusprophylaxe (15.04.2025) |
| RM08 |
Regulated handling of custodial measures DA Fixierung (Freiheitsentziehende Maßnahmen); Standard (A22) Mechanische Fixierung (19.01.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Organisationshandbuch Medizinproduktegesetzes KK Ebersberg (06.06.2023) |
| 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 OP-Statut (10.03.2025) |
| RM15 |
Preoperative, complete presentation of necessary findings präoperative Tumorkonferenzen, M&M Konferenzen, Frühbesprechungen (11.07.2025) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Patientensicherheit durch Patientenarmband, OP-Checklisten (25.09.2024) |
| RM17 |
Standards for recovery and postoperative care Standard Aufwachraum Haupt-OP (16.04.2025) |
| RM18 |
Discharge management Diverse Regelungen / Standards im Umgang mit Entlassmanagement vorhanden (04.03.2019) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
CIRS, Patientenarmbänder, OP-Checkliste, Checkliste für invasive Untersuchungen/Eingriffe, Team-time-out, Regelung für Patienten mit Heimbeatmung
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 23.07.2025 |
| IF02 |
Internal evaluation of the received reports taken bei Bedarf |
| 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: monatlich
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |