Dealing with risks in patient care
Quality management
Anja Genz
Qualitätsmanagementbeauftragte
Am Schlag 9
63654 Büdingen
Phone:
06042
-86-413
Mail:
ed.scinilcnamgreb@zneG.ajnA
Anja Genz
Qualitätsmanagementbeauftragte
Am Schlag 9
63654 Büdingen
Phone:
06042
-86-413
Mail:
ed.scinilcnamgreb@zneG.ajnA
QMB und Qualitätsmanagement-Moderatoren aller Klinikabteilungen.
Conference frequency: quartalsweise
Risk management
Im Rahmen der CIRS-Konferenz sind die Risiko- und Qualitätsmanagementbeauftragten Personen, die Klinikleitung sowie Chefärztinnen/ Chefärzte beteiligt.
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Einrichtungsinternes QM/ RM (30.12.2021) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Einrichtungsinternes QM/ RM (30.12.2021) |
| RM05 |
Pain management Einrichtungsinternes QM/ RM (30.12.2021) |
| RM06 |
Fall prophylaxis Einrichtungsinternes QM/ RM (30.12.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Einrichtungsinternes QM/ RM (30.12.2021) |
| RM08 |
Regulated handling of custodial measures Einrichtungsinternes QM/ RM (30.12.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices Einrichtungsinternes QM/ RM (30.12.2021) |
| 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 Einrichtungsinternes QM/ RM (30.12.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings Einrichtungsinternes QM/ RM (30.12.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Einrichtungsinternes QM/ RM (30.12.2021) |
| RM17 |
Standards for recovery and postoperative care Einrichtungsinternes QM/ RM (30.12.2021) |
| RM18 |
Discharge management Einrichtungsinternes QM/ RM (30.12.2021) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
- Patientenbefragungen - Beschwerdemanagement - Patientenidentifikationsarmbänder - Debriefing kritische klinische Zwischenfälle - CIRS (Critical Incident Reporting System) - Eingriffsverwechslung Chirurgie mittels Checkliste, Team Time Out - Morbiditäts- und Mortalitätskonferenzen - Klinisches Notfallmanagement - Prävention Medizinprodukte assoziierter Risiken (Verfahrensanweisung) - Umsetzung der gesetzlichen Richtlinien (MPG Beauftragte, MPG Schulungen)
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 21.07.2021 |
| 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: quartalsweise
| 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) |