Dealing with risks in patient care
Quality management
Heike Tiemann
Qualitätsmanagement
Liebenhaller Str. 20
38259 Salzgitter
Phone:
05341
-824-618
Mail:
ed.zs-htebasile-ts@h.nnameit
Das Gremium setzt sich wie folgt zusammen: Qualitätsmanagement, Organisationsentwicklung, Medizintechnik, Ärztlicher Dienst, Funktionsdienst
Conference frequency: quartalsweise
Risk management
Das Gremium setzt sich wie folgt zusammen: Qualitätsmanagement, Organisationsentwicklung, Medizintechnik, Ärztlicher Dienst, Funktionsdienst
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Unser Qualitätsmanagementsystem / Unser Risikomanagementsystem / Fehlermeldesystem (CIRS) (05.10.2023) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Verfahrensanweisung-Reanimation (06.05.2024) |
| RM05 |
Pain management Standard-Pflege-Expert-03 Schmerzmanagement (07.07.2024) |
| RM06 |
Fall prophylaxis Standard-Pflege-Expert-19 Sturzprävention (28.09.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Standard-Pflege-Expert-02 Dekubitusprophylaxe (19.08.2024) |
| RM08 |
Regulated handling of custodial measures Freiheitsentziehende Maßnahmen (21.04.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Anforderung Reparatur und Kennzeichnung defekter Geräte (30.09.2021) |
| 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 Verfahrensanweisung-OP-02 Time out (21.12.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings Verfahrensanweisung-OP-02 Time out (21.12.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Verfahrensanweisung-OP-02 Time out (21.12.2023) |
| RM17 |
Standards for recovery and postoperative care Standard-Anästhesie-32 (27.04.2022) |
| RM18 |
Discharge management Entlassmanagement / Expertenstandard Entlassmanagement (09.12.2021) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Durchführung regelmäßiger Audits mit anschließender Evaluation der ermittelten Daten.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 08.07.2021 |
| 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 jährlich |
Conference committee
Conference frequency: bei Bedarf
| No. | Explanation |
|---|---|
| EF02 |
CIRS Berlin (Berlin Medical Association, German Medical Association) |
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |
| EF14 |
CIRS Health Care |