Dealing with risks in patient care
Quality management
Kristiane Langer
externes Qualitätsmanagement
Bierdener Mühle 2
28832 Achim
Phone:
04202
-998-5000
Mail:
ed.kinilk-resew-rella@regnal-k
Geschäftsführung / Qualitätsmanagement
Conference frequency: monatlich
Risk management
Kristiane Langer
Externe Risikomanagerin
Bierdener Mühle 2
28832 Achim
Phone:
04202
-998-5000
Fax: 04202-998-7340
Mail:
ed.kinilk-resew-rella@regnal.k
Qualitätsmanagerin / Ärztlicher Direktor / Pflegedirektion / Geschäftsführung / Verwaltungsdirektion / externe Risikomanagerin
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Strategiepapier Risikomanagement (15.09.2022) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management AWA VA medizinisches Notfallmanagement VA Konzept innerklinischer medizinischer Notfall 2021 (15.05.2024) |
| RM05 |
Pain management AWA_Konzept_Perioperative_Schmerztherapie bei Erwachsenen (22.04.2024) |
| RM06 |
Fall prophylaxis VA Umgang mit Stürzen (19.06.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) VA Dekubitusprophylaxe (21.08.2023) |
| RM08 |
Regulated handling of custodial measures AWK VA Freiheitsentziehende Maßnahmen Betreuungsmaßnahme Amtsgericht Achim (08.01.2020) |
| RM09 |
Regulated handling of occurring malfunctions of devices AWA VA Umgang mit Medizinprodukte (13.01.2022) |
| 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 VA Team-Time-Out und Perioperative Checkliste / OP-Geschäftsordnung (09.04.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings OP-Geschäftsordnung (09.04.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups VA_Identifikationsarmband, VA_Vermeidung von Verwechslungen im OP (24.09.2020) |
| RM17 |
Standards for recovery and postoperative care AWK 141112 Verlegung AWR, AWK Nr.15 Aufwachraum (12.04.2023) |
| RM18 |
Discharge management AWK VA Entlassung (4.0) (10.05.2024) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Abschluss einer BV zur Einführung und Umsetzung eines anonymisierten Fehlermeldeverfahrens inkl. der Bearbeitung im Rahmen von CIRS-Gruppen unter der Moderation der exterenen Risikommanagerin.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 02.02.2024 |
| 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 jährlich |
Conference committee
Conference frequency: bei Bedarf
| No. | Explanation |
|---|---|
|
Other |
|
| EF02 |
CIRS Berlin (Berlin Medical Association, German Medical Association) |
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |
| EF06 |
CIRS NRW (North Rhine and Westphalia-Lippe Medical Associations, North Rhine-Westphalia Hospital Association, North Rhine and Westphalia-Lippe Associations of Statutory Health Insurance Physicians, German Medical Association) |