Dealing with risks in patient care

Quality management

Emily Schafft

Leitung Qualitätsmanagement

Seilerweg 29
36251 Bad Hersfeld

Phone: 06621 -88-922735
Mail: ed.feh-mukinilk@tffahcs.ylime

PDL, Leitung Intensivstation, Leitung Zentrallabor und Klinikhygiene, Qualitätsmanagement, Risikomanagement

Conference frequency: quartalsweise

Risk management

Emily Schafft

Leitung Qualitätsmanagement

Phone: 06621 -88-922735
Mail: ed.feh-mukinilk@tffahcs.ylime

PDL, Leitung Intensivstation, Leitung Zentrallabor und Klinikhygiene, Qualitätsmanagement/Risikomanagement, weitere Personen nach Themenschwerpunkt.

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Ablaufregel Klinisches Notfallmanagement (30.04.2019)

RM05

Pain management

Regelung Klinisches Schmerzmanagement (30.04.2019)

RM06

Fall prophylaxis

Umsetzung Expertenstandard Sturz (13.06.2016)

RM07

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

Wundmanagement (22.06.2022)

RM08

Regulated handling of custodial measures

Leitlinien für den Umgang mit Zwangsmaßnahmen, Dienstanweisung Fixierung (30.07.2019)

RM09

Regulated handling of occurring malfunctions of devices

Umsetzung des MPG und der MPBetreibV (04.11.2022)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Pathologiebesprechungen
  • Palliativbesprechungen
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-Checkliste, OP-Dokumentation (01.01.2016)

RM15

Preoperative, complete presentation of necessary findings

Checkliste OP,Team-Time-Out-Regelung (01.01.2016)

RM16

Procedure to avoid procedural and patient mix-ups

OP-Checkliste, Team-Time-Out, Patientenidentifikationsarmbänder (15.02.2019)

RM17

Standards for recovery and postoperative care

SOP Aufwachraum (08.04.2014)

RM18

Discharge management

In Anlehnung Expertenstandard Entlassung (02.06.2022)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Einführung Identifikationsarmbänder, Einführung Team-Time-Out, Anwendung OP-Checkliste, Regelung Überprüfung Patientendokumentation, Etikettierung IV-Medikation

No. Explanation
IF01

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

As of: 14.05.2013

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 halbjährlich

Conference committee

Conference frequency: