Dealing with risks in patient care

Quality management

Gabriele Damm

Leitung Qualitäts- und Risikomanagement

Fritzenwiese 15
29221 Celle

Phone: 0511 -8115-2712
Mail: ed.akh@mmad

Vorständin, Ärztliche Direktorin, Pflegedirektor, Kaufmännischer Direktor, Einrichtungsleitungen, Qualitäts- und Risikomanagement, Betriebsrat

Conference frequency: quartalsweise

Risk management

Agnes Genewein

Vorständin Hannoversche Kinderheilanstalt

Fritzenwiese 15
29221 Celle

Phone: 0511 -8115-1111
Fax: 0511-8115-1112
Mail: ed.akh@nieweneg.senga

Vorständin, Ärztliche Direktorin, Pflegedirektor, Kaufmännischer Direktor, Einrichtungsleitungen, Qualitäts- und Risikomanagement, Betriebsrat

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

Comprehensive quality and/or risk management documentation (QM/RM documentation) is available

QM-Organisationshandbuch (20.07.2023)

RM02

Regular further education and training measures

RM04

Clinical emergency management

QM-Organisationshandbuch (20.07.2023)

RM05

Pain management

QM-Organisationshandbuch (20.07.2023)

RM06

Fall prophylaxis

QM-Organisationshandbuch (20.07.2023)

RM07

Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”)

QM-Organisationshandbuch (20.07.2023)

RM08

Regulated handling of custodial measures

QM-Organisationshandbuch (20.07.2023)

RM09

Regulated handling of occurring malfunctions of devices

QM-Organisationshandbuch (20.07.2023)

RM12

Use of standardised information sheets

RM16

Procedure to avoid procedural and patient mix-ups

QM-Organisationshandbuch (20.07.2023)

RM18

Discharge management

QM-Organisationshandbuch (20.07.2023)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Entsprechend der jeweiligen Fälle

No. Explanation
IF01

Documentation and procedural instructions for handling the error reporting system are available

As of: 20.07.2023

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: monatlich

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)