St. Elisabeth Krankenhaus
Dealing with risks in patient care
Quality management
Christel Keim
Qualitätsmanagementbeauftragte
Warburger Straße 6
34471 Volkmarsen
Phone: 05693-680-111
Mail: ed.nesramklov-suahneknark-htebasile@miek.c
Standortübergreifende QM-Steuerungsgruppe. Teilnehmer: QMBs beider Standorte, Geschäftsführer, Pflegedirektion, Ärztlicher Direktor, Leitung Personalabteilung, Referent der Geschäftsführung.
Conference frequency: quartalsweise
Risk management
Qualitätsmanagementbeauftragte
Christel Keim
Phone: 05693-680-111
Fax: 05693-680-133
Mail: ed.nesramklov-suahneknark-htebasile@miek.c
Standortübergreifendes Risikokernteam. Teilnehmer: Risikomanager beider Standorte, Hygiene, Ärztlicher Dienst
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 (20.03.2018) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Umgang mit der Notfallausrüstung, diverse Checklisten (22.06.2022) |
| RM06 |
Fall prophylaxis Expertenstandard Sturz (29.04.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitus (04.11.2021) |
| RM08 |
Regulated handling of custodial measures Umgang mit freiheitsentziehenden Maßnahmen (20.03.2020) |
| RM09 |
Regulated handling of occurring malfunctions of devices Medizintechnik Handbuch (11.07.2022) |
| 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 Periinterventionelle Identifikations- und Sicherheitscheckliste (08.08.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings Periinterventionelle Identifikations- und Sicherheitscheckliste. (08.08.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Risikomanagement-Handbuch Qualitätsmanagement- Handbuch (20.03.2020) |
| RM17 |
Standards for recovery and postoperative care Postoperative Überwachung der Patienten im Aufwachraum (11.07.2022) |
| RM18 |
Discharge management Risikomanagement-Handbuch Qualitätsmanagement-Handbuch (20.03.2018) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Geräteersatzbeschaffungen; Optimierung Beschriftung Blutkonservenkühlschrank; Ausfallkonzept Telefonanlage, Schulung von Mitarbeitern; Überarbeitung von schriftlichen Standards; Verbesserung von Organisationsprozessen
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 17.09.2021 |
| 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) |