To the hospital’s home page

Marienkrankenhaus Kassel

Dealing with risks in patient care

Quality management

Gabriele Riedl

Unternehmensentwicklung/Qualitätsmanagement

Marburger Str. 85
34127 Kassel

Phone: 0561 -8073-1007
Mail: ed.lessak-suahneknarkneiram@ldeir.g

Standortübergreifende QM-Steuerungsgruppe. Teilnehmer: QMBs beider Standorte, Geschäftsführer, Pflegedirektion, Leitung Personalabteilung, ärztlicher Direktor

Conference frequency: quartalsweise

Risk management

Gabriele Riedl

Unternehmensentwicklung/Risikomanagement

Phone: 0561 -8073-1007
Fax: 0561-8073-4000
Mail: ed.lessak-suahneknarkneiram@ldeir.g

Standortübergreifende QM-Steuerungsgruppe. Teilnehmer: QMBs beider Standorte, Geschäftsführer, Pflegedirektion, Leitung Personalabteilung, ärztlicher Direktor

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2023)
RM02

Regular further education and training measures
RM03

Employee surveys
RM04

Clinical emergency management

Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2023)
RM05

Pain management

Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2023)
RM06

Fall prophylaxis

Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2023)
RM07

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

Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2023)
RM08

Regulated handling of custodial measures

Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2023)
RM09

Regulated handling of occurring malfunctions of devices

Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2023)
RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Palliativbesprechungen
  • Pathologiebesprechungen
  • Qualitätszirkel
  • Indikationsbesprechung; CED-Konferenzen; strukt. Röntgenbesprechungen
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

Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2023)
RM15

Preoperative, complete presentation of necessary findings

Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2023)
RM16

Procedure to avoid procedural and patient mix-ups

Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2023)
RM17

Standards for recovery and postoperative care

Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2023)
RM18

Discharge management

Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2023)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Fortbildungsangebote wurden angepasst; Fallkonferenzen weiterentwickelt; Im Rahmen der Digitalisierung weitere Tools z.B. im Rahmen der Arzneimittelsicherheit eingeführt

No. Explanation
IF01

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

As of: 06.11.2023
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 Association, German Nursing Council, German Medical Association)