Dealing with risks in patient care
Quality management
Armin Sülberg
Verwaltungsdirektor
Kurfürstenstraße 40
56864 Bad Bertrich
Phone:
02674
-940-0
Mail:
ed.scinilcnamgreb@grebleuS.nimrA
Prof. Dr. Christoph U. Herborn
CEO
Kurfürstenstraße 40
56864 Bad Bertrich
Phone:
02674
-940-0
Mail:
ed.scinilcnamgreb@kem.ofni
Nicole Bastian
Qualitätsmanagementbeauftragte
Kurfürstenstraße 40
56864 Bad Bertrich
Phone:
02674
-940-249
Mail:
ed.kinilk-lefie-lesom@naitsab.elocin
Geschäftsführung Controlling QM
Conference frequency: wöchentlich
Risk management
Armin Sülberg
Verwaltungsdirektor
Phone:
02674
-940-0
Fax: 02674-940-311
Mail:
ed.scinilcnamgreb@grebleuS.nimrA
Nicole Bastian
Qualitätsmanagementbeauftragte
Phone:
02674
-940-249
Mail:
ed.kinilk-lefie-lesom@naitsab.elocin
Geschäftsführung Controlling QM
Conference frequency: wöchentlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Interne Prozesskontrollen, Audits und Controlling (31.12.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Interne Prozesskontrollen, Audits und Controlling (31.12.2022) |
| RM05 |
Pain management Interne Prozesskontrollen, Audits und Controlling (31.12.2022) |
| RM06 |
Fall prophylaxis Interne Prozesskontrollen, Audits und Controlling (31.12.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Interne Prozesskontrollen, Audits und Controlling (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 |
| RM15 |
Preoperative, complete presentation of necessary findings Interne Prozesskontrollen, Audits und Controlling (31.12.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Interne Prozesskontrollen, Audits und Controlling (31.12.2022) |
| RM17 |
Standards for recovery and postoperative care Interne Prozesskontrollen, Audits und Controlling (31.12.2022) |
| RM18 |
Discharge management Zertifizierung DIN EN ISO 9001:2015 - 2. Überwachungsaudit (01.09.2020) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Begehungen Patientenbefragung Fehlererfassung Hygieneschulungen Umgesetzte Veränderungsmaßnahmen bzw. sonstige konkrete Maßnahmen zur Verbesserung der Patientensicherheit: für alle Bereiche, Coronaprophylaxe: Spezielle Patienteninformation, Eingangskontrollen
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 31.12.2022 |
| 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 jährlich |
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) |