Dealing with risks in patient care
Quality management
Dörthe Ihlenburg
Leitung Qualitätsmanagement
Sauerbruchstraße 7
38440 Wolfsburg
Phone:
05361
-80-2276
Mail:
ed.grubsflow.mukinilk@gnurehcissteatilauq
Frauenklinik; Urologie; Onkologie; Radiologie; Radioonkologie; Allgemein- und Viszeralchirurgie; Pathologie, Medizinische Direktorin
Conference frequency: quartalsweise
Risk management
Dörthe Ihlenburg
Leitung Qualitätsmanagement
Phone:
05361
-80-2276
Mail:
ed.grubsflow.mukinilk@gnurehcissteatilauq
1. wöchentlich: Team Risikomanagement-Koordination (RMK) 2. wöchentlich: RMK & Med. Direktorin 3. wöchentlich: RMK & Klinikumsdirektor 4. monatlich: RMK & Leitung Notaufnahme 5. quartalsweise: RMK & Direktorium 6. monatlich: Chefärzte, PDL, MD, RM, QM
Conference frequency: wöchentlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Organisationshandbuch Risikomanagment (28.10.2015) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Innerklinische Notfallalgorithmen (01.01.2019) |
| RM05 |
Pain management Verfahrensanweisung Multimodale stationäre Schmerztherapie (10.09.2014) |
| RM06 |
Fall prophylaxis Nationaler Expertenstandard: Verfahrensanweisung Sturzprophylaxe und -management (01.01.2020) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Nationaler Expertenstandard: Verfahrensanweisungen Dekubitusmanagement (01.02.2020) |
| RM08 |
Regulated handling of custodial measures Verfahrensanweisung Fixierung (03.02.2020) |
| RM09 |
Regulated handling of occurring malfunctions of devices Organisationshandbuch Medizintechnik (11.10.2021) |
| 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 Wolfsburger Sicherheits-Checkliste OP (05.10.2015) |
| RM15 |
Preoperative, complete presentation of necessary findings tägliche Röntgenbesprechung in den Medizinischen Kliniken, Unfallchirurgie, Urologie, HNO, Neurologie, Strahlentherapie und Frauenklinik (15.01.2006) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Verfahrensanweisung Wolfsburger Sicherheits-Checkliste OP Verfahrensanweisung für die Einführung der Patient*innenidentifikationsarmbändern Arbeitsanweisung Seitenmarkierung der operierenden Extremität (04.04.2013) |
| RM17 |
Standards for recovery and postoperative care Patientenpfad OP-Management inkl. Ein- und Ausschleusen (01.10.2020) |
| RM18 |
Discharge management Verfahrensanweisung Rahmenvertrag gem. §39 (1a) S.9 SGB V Entlassmanagement (Stand 19.3.2018). jährliche Auditierung des Prozesses/ Begehung des Entlassmanagement durch Fachpersonal (19.03.2018) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Optimierung der Klinikabläufe
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 08.03.2016 |
| 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:
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors) |
| EF14 |
CIRS Health Care |