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Universitätsklinikum Augsburg - Medizincampus

Dealing with risks in patient care

Quality management

Responsible person

Holger Jegust

Leiter Stabsstelle Qualitäts- und Risikomanagement

Stenglinstr. 2
86156 Augsburg

Phone: 0821 -400-4752
Mail: ed.grubsgua-ku@tsugej.regloh

Steering committee

Die Stabsstelle Qualitäts- und Risikomanagement berichtet monatlich auch zu QM- und RM-Themen dem Ärztlichen Direktor. Wöchentlich ist ein Jour Fix mit der Stabsstelle Interprofessionelle Klinikums- Entwicklung eingerichtet, in dem auch aktuelle Themen kommuniziert werden.

Conference frequency: monatlich

Risk management

Responsible person

Holger Jegust

Leiter Stabsstelle Qualitäts- und Risikomanagement

86009 Augsburg

Phone: 0821 -400-4752
Fax: 0821-400-4092
Mail: ed.grubsgua-ku@tsugej.regloh

Steering committee

Es ist ein monatlicher Jour Fix der Fachlichen Risikomanager eingerichtet, in dem aktuelle Risiken und die Weiterentwicklung des Systems besprochen werden.

Conference frequency: monatlich

Risk management instruments and measures

Instruments and measures

No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM-Dokumentation (26.07.2022)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management QM-Dokumentation (08.02.2023)
RM05	Pain management QM-Dokumentation (19.08.2021)
RM06	Fall prophylaxis QM-Dokumentation (16.08.2023)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) QM-Dokumentation (31.01.2020)
RM08	Regulated handling of custodial measures QM-Dokumentation (16.05.2024)
RM09	Regulated handling of occurring malfunctions of devices QM-Dokumentation (03.03.2023)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Palliativbesprechungen Qualitätszirkel Pathologiebesprechungen
RM12	Use of standardised information sheets
RM13	Application of standardised surgical check lists
RM16	Procedure to avoid procedural and patient mix-ups QM-Dokumentation (13.12.2021)
RM17	Standards for recovery and postoperative care QM-Dokumentation (20.12.2023)
RM18	Discharge management QM-Dokumentation (03.08.2022)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Ein Fehlermanagement (CIRS) ist flächendeckend in allen klinischen Bereichen eingeführt. Mitarbeiter anderer Bereiche können dieses System ebenfalls zur Fehlererfassung nutzen.

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 18.03.2022
IF02	Internal evaluation of the received reports taken jährlich
IF03	Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken jährlich

No.

Explanation

IF01

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

As of: 18.03.2022

IF02

Internal evaluation of the received reports

taken jährlich

IF03

Training of employees in handling the error reporting system and in implementing the findings from the error reporting system

taken jährlich

Across all institutions

Conference committee

Conference frequency: quartalsweise

No.	Explanation
EF01	CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association)