Dealing with risks in patient care

Quality management

Frau Anke-Sabine Schram

Standortverantwortliche Qualitätsmanagerin

Schöne Aussicht 39
98724 Neuhaus/Rwg.

Phone: 03675 -821-421
Mail: ed.nekinilk-demoiger@marhcS.eknA

Krankenhausleitung Leitender Chefarzt Pflegedirektion QS-Verantwortlicher Qualitätsmanagement Betriebsrat

Conference frequency: quartalsweise

Risk management

Krankenhausleitung Leitender Chefarzt Pflegedirektion QS-Verantwortlicher Qualitätsmanagement Betriebsrat

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

Qualido (31.12.2022)

RM02

Regular further education and training measures

RM04

Clinical emergency management

Qualido (31.12.2022)

RM05

Pain management

Qualido (31.12.2022)

RM06

Fall prophylaxis

Qualido (31.12.2022)

RM07

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

Qualido (31.12.2022)

RM08

Regulated handling of custodial measures

Qualido (31.12.2022)

RM09

Regulated handling of occurring malfunctions of devices

Qualido (31.12.2022)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Qualitätszirkel
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

Qualido (31.12.2022)

RM15

Preoperative, complete presentation of necessary findings

Qualido (31.12.2022)

RM16

Procedure to avoid procedural and patient mix-ups

Qualido (31.12.2022)

RM17

Standards for recovery and postoperative care

Qualido (31.12.2022)

RM18

Discharge management

Qualido (31.12.2022)

Fault reporting systems

Conference committee

Conference frequency: quartalsweise

Measures

Optimierung OP-Checkliste Sichere Identifizierung der Patienten durch Patienten-ID-Bänder Flyer des AKP "Sicher im Krankenhaus" Überarbeitung Dekubitus-Prophylaxe-Management Verschiedene Infoblätter zum Verhalten bei Noroviren, MRSA, VRE, Clostridien, Gastroenteritis, Krätze

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 quartalsweise

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