Dealing with risks in patient care
Quality management
Hochfeld Ramona
Leiterin Qualitäts- und Risikomanagement
Wolf Hirth Straße 18
36129 Gersfeld
Phone:
0661
-84-5151
Mail:
ed.adluf-mukinilk@dlefhcoh.anomar
QRM, Pflegedienstleitung, Betriebsrat, ärztlicher Dienst (v.a. aus der Klinik für Anästhesiologie, Intensiv- und Notfallmedizin)
Conference frequency: halbjährlich
Risk management
Hochfeld Ramona
Leiterin Qualitäts- und Risikomanagement
Wolf Hirth Straße 18
36129 Gersfeld
Phone:
0661
-84-5151
Mail:
ed.adluf-mukinilk@dlefhcoh.anomar
QRM, Finanz- und Rechnungswesen, alle Abteilungsleiter, Informationssicherheit
Conference frequency: halbjährlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Zentrales QM Handbuch (14.04.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Zentrales QM Handbuch (14.04.2022) |
| RM05 |
Pain management Zentrales QM Handbuch (11.02.2022) |
| RM06 |
Fall prophylaxis Zentrales QM Handbuch (14.04.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Zentrales QM Handbuch (27.05.2021) |
| RM08 |
Regulated handling of custodial measures Zentrales QM Handbuch (27.04.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Zentrales QM Handbuch (15.05.2023) |
| 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 Zentrales QM Handbuch (14.05.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings Zentrales QM Handbuch (14.05.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Zentrales QM Handbuch (21.06.2023) |
| RM17 |
Standards for recovery and postoperative care Zentrales QM Handbuch (21.06.2023) |
| RM18 |
Discharge management Zentrales QM Handbuch (12.05.2022) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Überarbeitung der OP-Sicherheits-Checkliste; Umsetzung von Handlungsempfehlungen des Aktionsbündnisses Patientensicherheit; Teilnahme an der "Aktion Saubere Hände"; Patientenidentifikation: Patienten-Armbänder. Grundsätzlich kann jeder Mitarbeiter eine CIRS-Meldung und Generelle Risiken per Intranetformular jederzeit abgeben.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 13.01.2023 |
| 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 monatlich |
Conference committee
Conference frequency: halbjährlich
| No. | Explanation |
|---|---|
|
Other |