Dealing with risks in patient care

Quality management

Andreas Kelpe

Ltr. QM

Bahnhofstraße 2-4
99867 Gotha

Phone: 03601 -803-841
Mail: ed.kheo@mq

QM-Lenkungsgremium (Stabsstelle QM + Krankenhausleitung) und QM-Arbeitskreis (Stabsstelle QM + interdisziplinäre Teilnehmende)

Conference frequency: monatlich

Risk management

Andreas Kelpe

Ltr. QM

Bahnhofstraße 2-4
99867 Gotha

Phone: 03601 -803-841
Fax: 03601-803-266
Mail: ed.kheo@mq

QM-Lenkungsgremium (Stabsstelle QM + Krankenhausleitung) und QM-Arbeitskreis (Stabsstelle QM + interdisziplinäre Teilnehmende)

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

Comprehensive quality and/or risk management documentation (QM/RM documentation) is available

VA Risikomanagement (D1015) (03.08.2023)

RM02

Regular further education and training measures

RM04

Clinical emergency management

VA Medizinisches Notfallkonzept (D3946) (18.02.2022)

RM05

Pain management

VA Schmerztherapie (11.10.2021)

RM06

Fall prophylaxis

VA Sturzprophylaxe (Expertenstandard) (10.09.2020)

RM07

Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”)

VA Dekubitusprophylaxe (Expertenstandard) (15.06.2020)

RM08

Regulated handling of custodial measures

VA Richtlinie zur Fixierung eines Patienten (D1666); VA Anordnung besondere Schutz und Sicherungsmaßnahmen (D531) (13.10.2020)

RM09

Regulated handling of occurring malfunctions of devices

VA Umgang mit Medizinprodukten (D2775) (25.10.2021)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Mortalitäts- und Morbiditätskonferenzen
RM12

Use of standardised information sheets

RM18

Discharge management

VA Entlassmanagement (D788) (14.10.2021)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Etablierung: CIRS, Meinungsmanagement, Risikomanagement, medizinisches Notfallkonzept

No. Explanation
IF01

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

As of: 03.08.2023

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 jährlich

Conference committee

Conference frequency: monatlich

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)