Dealing with risks in patient care
Quality management
Björn-Ola Fechner
Leitung Abteilung für Organisation, Qualitätsmanagement, Tumordokumentation und Study Nurse
Esmarchstraße 50
25746 Heide
Phone:
0481
-785-1015
Mail:
ed.ieh-kkw@renhcefb
Regelmäßige Qualiätsgespräche mit allen verantwortlichen Personen
Conference frequency: quartalsweise
Risk management
Björn-Ola Fechner
Zertifizierter klinischer Risikomanager nach ONR 49003:2014
Phone:
0481
-785-1015
Fax: 0481-785-1021
Mail:
ed.ieh-kkw@ofni
Geschäftsführung Krankenhausdirektorium Risikokoordinator Risikomanager Risikobeauftragte
Conference frequency: halbjährlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available VA Risikomanagement ID 656 (20.02.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Verhalten bei hausinternen Notfällen Heide ID: 480 (26.10.2023) |
| RM05 |
Pain management Schmerzmanagement ID: 1868 (12.05.2022) |
| RM06 |
Fall prophylaxis 1 Leitlinie zum Expertenstandard Sturzprophylaxe ID 1698 (13.05.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Systematisches Dekubitusmanagement ID 31672 (15.02.2022) |
| RM08 |
Regulated handling of custodial measures Freiheitsentziehende Maßnahmen bei Patienten ID 552 (11.12.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices Meldung Vorkommnis Medizinprodukte ID 630 (10.06.2022) |
| 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 Prävention Eingriffsverwechselung ID 626 (30.05.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings Basis-Checkliste zur Vorbereitung operativer Eingriffe ID 22892 (01.09.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Prävention von Eingriffsverwechslungen ID 626 (22.07.2022) |
| RM17 |
Standards for recovery and postoperative care Narkoseprotokoll ID18262 (30.06.2023) |
| RM18 |
Discharge management Dienstanweisung Entlassungsmanagement ID:528 (22.07.2022) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Folgende konkrete Maßnahmen zur Verbesserung der Patienten¬sicherheit sind erfolgt: *Etiketten mit neuem Nummernkreis für das Labor *getrennte Lagerung der Medikamente, Abfragung von Schulungsbedarf in den Abteilungen, Sensibilisierung der Teams * Sensibilisierung des Teams Radiologie in Bezug auf die Befundweitergabe * Sensibilisierung der Teams in Bezug auf die Team-Time-Out Bögen über die Chefarztrunde
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 26.06.2023 |
| IF02 |
Internal evaluation of the received reports taken monatlich |
| 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 |
|---|---|
|
Other |
|
| EF01 |
CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association, National Association of Statutory Health Insurance Doctors) |
| EF02 |
CIRS Berlin (Medical Association Berlin, German Medical Association, National Association of Statutory Health Insurance Doctors) |