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DRK Krankenhaus Altenkirchen-Hachenburg (HB)

Dealing with risks in patient care

Quality management

Responsible person

Herr Dennis Wesemann

Beauftragter für das Qualitäts- und Risikomanagement

Alte Frankfurter Straße 12
57627 Hachenburg

Phone: 02662 -85-5036
Mail: ed.grubnehcah-hk-krd@nnamesew.sinned

Steering committee

Krankenhausdirektorium, Beauftragter für das Qualitäts- und Risikomanagement, Risikokoordinatoren Ärzte, Risikokoordinatoren Pflege, Betriebsratsvorsitzender Standort Altenkirchen, Betriebsratsvorsitzender Standort Hachenburg

Conference frequency: monatlich

Risk management

Responsible person

Dennis Wesemann

Beauftragter für das Qualitäts- und Risikomanagement

Phone: 02662 -85-2036
Fax: 02662-85-2002
Mail: ed.grubnehcah-hk-krd@nnamesew.sinned

Steering committee

Conference frequency: monatlich

Risk management instruments and measures

Instruments and measures

No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Systemhandbuch Qualitäts- und Risikomanagement der DRK Trägergesellschaft Süd-West mbH (fortlaufende Aktualisierung der Einzelkapitel und -dokumente, regelmäßiger Sonderdruck einer Gesamtausgabe) (17.11.2020)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Notfallkonzept (22.02.2023)
RM05	Pain management Standard Schmerzmanagement bei akuten Schmerzen (30.07.2019)
RM06	Fall prophylaxis Standard Sturzprophylaxe (03.06.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Standard Dekubitusprophylaxe (28.02.2019)
RM08	Regulated handling of custodial measures Fixierungsrichtlinie (02.11.2020)
RM09	Regulated handling of occurring malfunctions of devices Organisationshandbuch Medizintechnik (20.03.2023)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Mortalitäts- und Morbiditätskonferenzen Qualitätszirkel Monatliche Komplikationsbesprechungen in der Orthopädie Fall-/Teambesprechungen OP-Konferenzen Kreißsaalkonferenzen
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 OP-Sicherheitscheckliste (17.02.2022)
RM15	Preoperative, complete presentation of necessary findings OP-Sicherheitscheckliste (17.02.2022)
RM16	Procedure to avoid procedural and patient mix-ups VA Elektive Eingriffe (03.10.2019)
RM17	Standards for recovery and postoperative care VA Elektive Eingriffe (03.10.2019)
RM18	Discharge management VA Entlassmanagement (17.02.2020)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Eindeutige Festlegung von Kommunikationsregeln zur gesicherten Vermeidung von Verwechslungen (read-back/repeat-back-Prinzip))

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 30.06.2021
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 bei Bedarf

No.

Explanation

IF01

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

As of: 30.06.2021

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 bei Bedarf

Across all institutions

Conference committee

Conference frequency: monatlich

No.	Explanation
EF01	CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association, National Association of Statutory Health Insurance Doctors)