Dealing with risks in patient care
Quality management
Sandra Lehmann
Qualitätsbeauftragte
Berliner Straße 24
15926 Luckau
Phone:
03544
-58-247
Mail:
ed.suahnessinokaid@nnamhel.ardnas
Geschäftsführung Unternehmensbereich Gesundheit, Ärztliche Direktion, Kaufmännische Direktion, Pflegedirektion, zentrales und internes Qualitätsmanagement
Conference frequency: monatlich
Risk management
Ulrike Jäkel
Prozessverantwortlicher für das klinische Riskomanagement
Phone:
03544
-58-161
Fax: 03544-58-165
Mail:
ed.suahnessinokaid@lekeaj.ekirlu
Vorstand; Referat Strategie- und Risikomanagement; Geschäftsführung Unternehmensbereich Gesundheit; Klinikleitung; zentrales und internes Qualitätsmanagement
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikoatlas (30.12.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Notfallkonzept (16.06.2023) |
| RM05 |
Pain management Expertenstandard Schmerzmanagement in der Pflege bei akuten Schmerzen (30.09.2021) |
| RM06 |
Fall prophylaxis Expertenstandard Sturzprophylaxe in der Pflege (30.09.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitusprophylaxe in der Pflege (30.09.2021) |
| RM08 |
Regulated handling of custodial measures Prozessbeschreibung "Freiheitsentziehende Maßnahmen" (25.09.2019) |
| RM09 |
Regulated handling of occurring malfunctions of devices Handbuch "Umgang mit Medizinprodukten" (28.08.2022) |
| 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 OP-Sicherheitscheckliste, Anästhesieprotokoll (27.03.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Prozessbeschreibung "Umgang mit dem Patientenidentifikationsarmband" (02.09.2022) |
| RM17 |
Standards for recovery and postoperative care OP-Sicherheitscheckliste (24.07.2023) |
| RM18 |
Discharge management Expertenstandard Entlassungsmanagement in der Pflege (26.03.2020) |
Fault reporting systems
Conference committee
Conference frequency: jährlich
Measures
Teilnahme an der Aktion Saubere Hände, Überarbeitung von Dokumenten, Durchführung von Schulungen
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 18.10.2023 |
| 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: bei Bedarf
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |
| EF06 |
CIRS NRW (North Rhine and Westphalia-Lippe Medical Associations, North Rhine-Westphalia Hospital Association, North Rhine and Westphalia-Lippe Associations of Statutory Health Insurance Physicians, German Medical Association) |