Dealing with risks in patient care
Quality management
Dr. Martina Oldhafer
Leitung Unternehmensorganisation
Oeninger Weg 30
29614 Soltau
Phone:
05191
-602-3210
Mail:
ed.mukinilk-sierkedieh@refahdlo.anitram
Geschäftsführung Qualitätsentwicklung/Risikomanagement Zentrale Dienste
Conference frequency: wöchentlich
Risk management
Martina Oldhafer
Leitung Unternehmensorganisation
Oeninger Weg 30
29614 Soltau
Phone:
05191
-602-3210
Fax: 05191-602-3286
Mail:
ed.mukinilk-sierkedieh@refahdlo.anitram
Geschäftsführung Qualitätsentwicklung/Risikomanagement Zentrale Dienste
Conference frequency: wöchentlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM-Handbuch, Apenio und andere (15.03.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management QM-Handbuch, Apenio und andere (15.03.2022) |
| RM05 |
Pain management QM-Handbuch, Apenio und andere (15.03.2022) |
| RM06 |
Fall prophylaxis QM-Handbuch, Apenio und andere (15.03.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) QM-Handbuch, Apenio und andere (15.03.2022) |
| RM08 |
Regulated handling of custodial measures QM-Handbuch, Apenio und andere (15.03.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices QM-Handbuch, Apenio und andere (15.03.2022) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM13 |
Application of standardised surgical check lists |
| RM15 |
Preoperative, complete presentation of necessary findings QM-Handbuch, Apenio und andere (15.03.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups QM-Handbuch, Apenio und andere (15.03.2022) |
| RM17 |
Standards for recovery and postoperative care QM-Handbuch, Apenio und andere (15.03.2022) |
| RM18 |
Discharge management QM-Handbuch, Apenio und andere (15.03.2022) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Mit den per Verfahrensanweisung geregelten Meldesystemen CIRS dem Beschwerdemanagement sowie der Verfahrensanweisung für unerwünschte Ereignisse werden die Fehler erfasst, analysiert und auf der Grundlage des Qualitätsmanagementzyklus bearbeitet. CIRS=Critical Incident Reporting System
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 07.01.2022 |
| 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 monatlich |
Conference committee
Conference frequency: bei Bedarf
| No. | Explanation |
|---|---|
|
Other |
|
| EF01 |
CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association) |