Dealing with risks in patient care
Quality management
Denise Apelt
Leitung Qualitäts- und Risikomanagement
Grabmannstraße 9
85072 Eichstätt
Phone:
08421
-601-9399
Mail:
moc.znaillakinilk@tlepa.esined
Der Vorstand lädt zur monatlichen Direktoriumskonferenz (Vorstand, Chefärzte, Betriebsdirektoren, Pflegedirektion) ein. Themen des Qualitätsmanagements werden anlassbezogen dargestellt.
Conference frequency: monatlich
Risk management
Denise Apelt
Leitung Qualitäts- und Risikomanagement
Grabmannstraße 9
85072 Eichstätt
Phone:
08421
-601-9399
Mail:
moc.znaillakinilk@tlepa.esined
Der Vorstand lädt zur monatlichen Direktoriumskonferenz (Vorstand, Chefärzte, Betriebsdirektoren, Pflegedirektion) ein. Themen des Qualitätsmanagements werden anlassbezogen dargestellt.
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Dienstanweisung Klinisches Risikomanagement - CIRS (01.07.2025) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Vorgehen im Notfall (15.01.2024) |
| RM05 |
Pain management Standard: Schmerztherapie Standard: Umgang mit Schmerzkathetern, Standard: Schmerztherapie Expertenstandard (28.05.2025) |
| RM06 |
Fall prophylaxis Pflegestandard Sturzprophylaxe (31.07.2025) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitusprophylaxe (08.04.2025) |
| RM08 |
Regulated handling of custodial measures Dienstanweisung zur Fixierung von Patienten (22.03.2024) |
| RM09 |
Regulated handling of occurring malfunctions of devices Organisationshandbuch Medizintechnik, Prozessbeschreibung Haustechnik (09.10.2023) |
| 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 Dienstanweisung OP-Sicherheitscheckliste, Transfusionsmedizinische Dienstanweisung, Präoperative Checkliste, Präoperative Blutgruppenbestimmung und Blutkonserven (27.08.2025) |
| RM15 |
Preoperative, complete presentation of necessary findings Präoperative OP-Checkliste (22.05.2025) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Dienstanweisung OP-Sicherheitscheckliste, Patientensicherheitscheckliste WHO, Patientenidentifikationsarmband Anwendung und Umgang (06.10.2023) |
| RM17 |
Standards for recovery and postoperative care Standards Aufwachraum, Pflegestandard: postoperative Pflegemaßnahmen im Aufwachraum (24.01.2025) |
| RM18 |
Discharge management Handbuch Entlassungsmanagement (03.07.2023) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Fehlersammellisten, Aktualisierung der präoperativen OP-Checkliste und der Patientensicherheitscheckliste (WHO)
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 06.10.2023 |
| 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: jährlich
| No. | Explanation |
|---|---|
| EF01 |
CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association) |