Dealing with risks in patient care
Quality management
Diplom-Pflegewirt (FH) Frank Schwietert
Qualitätsmanagementbeauftragter
Danziger Straße 2
49610 Quakenbrück
Phone:
05431
-15-2669
Mail:
ed.hbmg-qkc@treteiwhcs.f
Geschäftsführung, Pflegedirektion, Ärztliche Direktion, andere Abteilungen bei Bedarf
Conference frequency: bei Bedarf
Risk management
Till Puncak
Qualitätsmanagementbeauftragter/Risikomanagement
Danziger Str. 2
49610 Quakenbrück
Phone:
05431
-15-1863
Fax: 05431-15-1803
Mail:
ed.hbmg-qkc@kacnup.t
Geschäftsführung, Pflegedirektion, Ärztliche Direktion, andere Abteilungen bei Bedarf
Conference frequency: bei Bedarf
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitätsmanagementhandbuch; Interne und externe Audits (03.02.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Qualitätsmanagementhandbuch; Interne und externe Audits (03.02.2022) |
| RM05 |
Pain management Qualitätsmanagementhandbuch; Interne und externe Audits (12.05.2022) |
| RM06 |
Fall prophylaxis Qualitätsmanagementhandbuch; Interne und externe Audits (07.09.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Qualitätsmanagementhandbuch; Interne und externe Audits (24.01.2020) |
| RM08 |
Regulated handling of custodial measures Qualitätsmanagementhandbuch; Interne und externe Audits (08.04.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices Qualitätsmanagementhandbuch; Interne und externe Audits (04.09.2023) |
| 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 Qualitätsmanagementhandbuch; Interne und externe Audits (08.05.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings Qualitätsmanagementhandbuch; Interne und externe Audits (09.03.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups OP-Checkliste; Interne und externe Audits (09.03.2021) |
| RM17 |
Standards for recovery and postoperative care Qualitätsmanagementhandbuch; Interne und externe Audits (09.03.2021) |
| RM18 |
Discharge management Qualitätsmanagementhandbuch; Interne und externe Audits (07.09.2021) |
Fault reporting systems
Conference committee
Conference frequency: wöchentlich
Measures
4-Augen-Prinzip bei Medikamentengabe, Anwendung von OP-Checklisten, Einsatz von Patientenarmbändern zur Identifikation, Hinweisschilder im MRT zum Verhalten für Patienten mit Insulinpumpen u. a.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 17.07.2019 |
| 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: wöchentlich
| No. | Explanation |
|---|---|
| EF14 |
CIRS Health Care |