Dealing with risks in patient care
Quality management
Dipl. Betriebsw. Julia Heubel
Leitung Qualitätsmanagment
Haubensteigweg 40
87439 Kempten
Phone:
0821
-2412-585
Mail:
ed.munifesoj@mq
Klinikleitung, Ärztlicher Direktor, Verwaltungsdirektor, Pflegedirektorin, Qualitätsmanagementbeauftragte
Conference frequency: quartalsweise
Risk management
Julia Heubel
Leitung Qualitätsmanagement
Haubensteigweg 40
87439 Kempten
Phone:
0821
-2412-585
Mail:
ed.munifesoj@mq
Klinikleitung, Ärztlicher Direktor, Verwaltungsdirektor, Pflegedirektorin, Qualitätsmanagementbeauftragte
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available JOS_VA_Risikoüberwachung (25.01.2021) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management JOS_VA_Notfall (18.03.2022) |
| RM05 |
Pain management z.B. Schmerzmanagement in der KJPP nach dem Expertenstandard des DNQP (2020); Schmerzmanagement im Josefinum nach dem Expertenstandard des DNQP (2020) (17.08.2021) |
| RM06 |
Fall prophylaxis JOS_VA_ Sturzmanagement, Sturzprophylaxe nach dem Expertenstandard des DNQP (2013) (30.12.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) z.B. Dekubitusprophylaxe und -pflege nach dem Expertendstandard des DNQP (2017) (23.03.2022) |
| RM08 |
Regulated handling of custodial measures KJPP_S_Fixierungen (02.02.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices JOS_VA_defektes Medizinprodukt (29.06.2020) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM18 |
Discharge management JOS_VA_Entlassmanagement (09.08.2021) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
z.B. anonymsierte Veröffentlichung von unerwünschten Ereignissen im Mitarbeiterportal, Implementierung des gesetzlichen Entlassmanagements, strukturiertes Risikomanagement mit jährlicher Evaluation klinikbezogener Risiken
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 05.09.2023 |
| 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 |
|---|---|
| EF03 |
KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors) |