Dealing with risks in patient care
Quality management
Dipl. Pflegewirt (FH) Sebastian Friedrichs
Leitung Qualitätsmanagement (QMB)
Waldstraße 17
24939 Flensburg
Phone:
0461
-816-2510
Mail:
gro.resetlam@shcirdeirF.naitsabeS
Direktorium mit QMB/ Risikomanager
Conference frequency: andere Frequenz
Risk management
Sebastian Friedrichs
Leitung Qualitätsmanagement (QMB)
24917 Flensburg
Phone:
0461
-816-2510
Fax: 0461-816-2012
Mail:
gro.resetlam@shcirdeirF.naitsabeS
Direktorium mit QMB/ Risikomanager
Conference frequency: andere Frequenz
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM-Handbücher & Abteilungsdokumente (22.08.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management QM-Handbuch (24.01.2022) |
| RM05 |
Pain management QM-Handbuch (19.09.2022) |
| RM06 |
Fall prophylaxis QM-Handbuch (20.04.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) QM-Handbuch (17.04.2023) |
| RM08 |
Regulated handling of custodial measures QM-Handbuch (14.06.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices QM-Handbuch (10.08.2023) |
| 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 Chirurgischen Frühbesprechung sowie im Rahmen des Team Time Outs, OP-Sicherheitscheckliste (04.03.2020) |
| RM15 |
Preoperative, complete presentation of necessary findings Röntgenbesprechung, chirurgische Frühbesprechung, OP-Sichrheitscheckliste (04.03.2020) |
| RM16 |
Procedure to avoid procedural and patient mix-ups QM-Handbuch (11.01.2022) |
| RM17 |
Standards for recovery and postoperative care QM-Handbuch (12.09.2022) |
| RM18 |
Discharge management QM-Handbuch (11.01.2022) |
Fault reporting systems
Conference committee
Conference frequency: andere Frequenz
Measures
Patienten-& Allergiearmbänder, Wirkstoffanordnungen, Checklisten in OP & Diagnostikzentrum, Fortbildungsmaßnahmen, Verfahrensanweisungen zum klinischen RM - zum Fehlernumgang -zu CIRS, Laufende Optimierung von Verfahrens- & Prozessbeschreibungen, Sturz- & Dekubitusprävention, Beschwerdemanagement, Team Time out, M&M-Konferenzen, CIRS, interprofessionelle & interdisziplinäre Risikokommission mit Geschäftsordnung, systematische Bewertung klinischer Risiken, DIN ISO 9001:2015 Apotheke, IQM
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 15.12.2020 |
| 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: andere Frequenz
| 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) |