Dealing with risks in patient care
Quality management
Monika Hilbert-Jansen
Leitung Qualitätsmanagement
Ilseder Straße 35
31226 Peine
Phone:
05353
-90-1451
Mail:
ed.zpa-owa@nesnaJ-trebliH.akinoM
Geschäftsführer, Ärztlicher Direktor, Pflegedirektorin, Chefärzte aller Kliniken, Leitende Ärzte Allgemeinpsychiatrie, Betriebsratsvorsitzende, Leiterin Qualitätsmanagement
Conference frequency: monatlich
Risk management
Martin Eisoldt
Risikomanagementbeauftragter
Ilseder Straße 35
31226 Peine
Phone:
05353
-90-1121
Mail:
ed.zpa-owa@tdlosiE.nitraM
Martin Eisoldt
Risikomanagementbeauftragter
Ilseder Straße 35
31226 Peine
Phone:
05353
-90-1121
Mail:
ed.zpa-owa@tdlosiE.nitraM
Ärztin, Pflegekräfte, Finanzmanagement, Arbeitssicherheit, IT-Abteilung, Facilitymanagement, QM
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available VA II.1.11-1 Fehler- und Risikomanagement, VA II.1.11-2 Risikoidentifizierung und -bewertung (20.05.2021) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management VA III.1.4-1 Medizinisches Notfallmanagement (01.06.2016) |
| RM05 |
Pain management Expertenstandard Schmerz (10.07.2019) |
| RM06 |
Fall prophylaxis Expertenstandard Sturzprophylaxe (10.07.2019) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Standard Dekubitusprophylaxe (21.08.2020) |
| RM08 |
Regulated handling of custodial measures Workflow im Krankenhausinformationssystem (01.05.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices VA II.4.1-1 Reparaturaufträge, VA II.4.1-2 Wartungsmanagement (04.03.2019) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM18 |
Discharge management VA III.1.2.4-1 Entlassung (06.09.2021) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Hygienemaßnahmen, Suizidvermeidung, Personennotrufanlage, Medikation - Minimierung von Verwechslungsrisiken Medikation - Verbesserung der Dokumentationsqualität, Umgang mit aggressiven Patienten (PART-Schulungen)
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 20.05.2021 |
| 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 bei Bedarf |
Conference committee
Conference frequency: