Dealing with risks in patient care
Quality management
Herr Timo Hampel
Teamleitung QM
An der Lutter 24
37075 Göttingen
Phone:
0551
-5034-1898
Mail:
ed.edneewke@mq
Der QM-Lenkungskreis besteht aus 13 Personen aus den Bereichen: Medizinische Geschäftsführung, Qualitätsmanagement, Medizincontrolling, Arzt- und Pflegedienst, Beschwerdemanagement, Mitarbeitervetretung, Sozialdienst und Krankenhaushygiene. Der QM-Lenkungskreis tagt dreimal jährlich.
Conference frequency: andere Frequenz
Risk management
Timo Hampel
Teamleitung QM
An der Lutter 24
37075 Göttingen
Phone:
0551
-5034-1898
Fax: 0551-5034-1514
Mail:
ed.edneewke@mq
Der Arbeitskreis Risikomanagement besteht aus Mitarbeitern der Bereiche: Medizinische Geschäftsführung, Qualitätsmanagement, Arzt- und Pflegedienst, Beschwerdemanagement, Schadensfallmanagement, Arbeitssicherheit, Krankenhaushygiene. Der AK trifft sich 3x jährlich.
Conference frequency: andere Frequenz
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available roXtra (06.08.2019) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management roXtra (06.08.2019) |
| RM05 |
Pain management roXtra (06.08.2019) |
| RM06 |
Fall prophylaxis roXtra (06.08.2019) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) roXtra (06.08.2019) |
| RM08 |
Regulated handling of custodial measures roXtra (06.08.2019) |
| RM09 |
Regulated handling of occurring malfunctions of devices roXtra (06.08.2019) |
| 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 roXtra (06.08.2019) |
| RM15 |
Preoperative, complete presentation of necessary findings roXtra (06.08.2019) |
| RM16 |
Procedure to avoid procedural and patient mix-ups OP-Statut (28.11.2019) |
| RM17 |
Standards for recovery and postoperative care roXtra (06.08.2019) |
| RM18 |
Discharge management roXtra (06.08.2019) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Die eingehenden Meldungen werden von einem fachlich versiertem CIRS - Team von Ärzten, Pflegekräften und Qualitätsmanagern analysiert und bewertet. Es werden konkrete Handlungsmaßnahmen zur Erhöhung der Patientensicherheit abgeleitet und z.B. in Form einer SOP/Dienstanweisung in das bestehende QM - System implementiert.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 22.08.2023 |
| 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) |
| EF14 |
CIRS Health Care |