Dealing with risks in patient care
Quality management
Dr. med. Jule Wenke Winkler
Leitung Qualitätsmanagement/ Krankenhaushygiene
Weiße Mauer 52
06217 Merseburg
Phone:
03461
-27-1007
Mail:
ed.sierkelaas-mukinilk@relkniw.wj
Qualitätskommission bestehend aus: Geschäftsführer, Prokurist, Ärztlicher Direktor, Pflegedienstdirektorin, Standortleitung, Vertreter Betriebsrat, Leitung Hygiene und Qualitätsmanagement, Qualitätsbeauftragte, Qualitätsmanagerin,
Conference frequency: quartalsweise
Risk management
Qualitätskommission bestehend aus: Geschäftsführer, Prokurist, Ärztlicher Direktor, Pflegedienstdirektorin, Standortleitung, Vertreter Betriebsrat, Leitung Hygiene und Qualitätsmanagement, Qualitätsbeauftragte, Qualitätsmanagerin,
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available DMS Roxtra (31.12.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management DMS Roxtra (31.12.2022) |
| RM05 |
Pain management DMS Roxtra (31.12.2022) |
| RM06 |
Fall prophylaxis DMS Roxtra (31.12.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) DMS Roxtra (31.12.2022) |
| RM08 |
Regulated handling of custodial measures DMS Roxtra (31.12.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices DMS Roxtra (31.12.2022) |
| 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 DMS Roxtra (31.12.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings DMS Roxtra (31.12.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups DMS Roxtra (31.12.2022) |
| RM17 |
Standards for recovery and postoperative care DMS Roxtra (31.12.2022) |
| RM18 |
Discharge management DMS Roxtra (31.12.2022) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
CIRS-Meldungen Einsatz von Patientenidentifikationsarmbändern POCT-Geräte M & M Konferenzen Interne Audits OP-Sicherheitscheckliste
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 28.01.2021 |
| 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: 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) |