Dealing with risks in patient care

Quality management

A. Fischer

Qualitätsmanagement

Keltenstraße 67
97318 Kitzingen

Phone: 09321 -704-4412
Mail: ed.lk-k@rehcsif.ardnaxela

Vorstand, Leitungsrunde, QM

Conference frequency: monatlich

Risk management

A. Fischer

Qualitätsmanagement

Keltenstraße 67
97318 Kitzingen

Phone: 09321 -704-4412
Fax: 09321-704-4449
Mail: ed.lk-k@rehcsif.ardnaxela

C. Sommer

Chefarzt Notaufnahme

Keltenstraße 67
97318 Kitzingen

Phone: 09321 -704-1100
Fax: 09321-704-4449
Mail: ed.lk-k@mrk

QM, Pflege, Ärzte

Conference frequency: andere Frequenz

Risk management instruments and measures

No. Explanation
RM01

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

Berichte zum Risiko-Assessment (12.05.2023)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

"Schockraum-Manual" (02.05.2021)

RM05

Pain management

Expertenstandard Schmerzmanagement (08.05.2023)

RM06

Fall prophylaxis

Expertenstandard Sturzprophylaxe (20.02.2023)

RM07

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

SOP "Dekubitusprophylaxe" (18.04.2023)

RM08

Regulated handling of custodial measures

Freiheitseinschränkende Maßnahmen (17.04.2023)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
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

WHO Sicherheits-Checkliste (03.11.2022)

RM15

Preoperative, complete presentation of necessary findings

WHO Sicherheits-Checkliste (03.11.2022)

RM16

Procedure to avoid procedural and patient mix-ups

WHO Sicherheits-Checkliste (03.11.2022)

RM17

Standards for recovery and postoperative care

Postoperative Überwachung (07.12.2021)

RM18

Discharge management

Entlassmanagement (21.06.2022)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Ergibt sich aus den jeweiligen Meldungen.

No. Explanation
IF01

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

As of: 06.12.2022

IF02

Internal evaluation of the received reports

taken jährlich

IF03

Training of employees in handling the error reporting system and in implementing the findings from the error reporting system

taken jährlich

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)