St. Georg Klinikum Eisenach gemeinnützige GmbH
Dealing with risks in patient care
Quality management
Frau Tina Rohrbach
Qualitätsmanagementbeauftragte
Mühlhäuser Straße 94-95
99817 Eisenach
Phone: 03691-698-1130
Mail: ed.mukinilkgroegts@aniT.hcabrhoR
z.B. Qualitätszirkel , CIRS-Team, Krankenhausbetriebsleitung, Chefarztkonferenz, Stationsleitungsbesprechungen, Tumorkonferenzen
Conference frequency: monatlich
Risk management
Qualitätsmanagementbeauftragte
Tina Rohrbach
99817 Eisenach
Phone: 03691-698-1130
Mail: ed.mukinilkgroegts@aniT.hcabrhoR
CIRS Team
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Leitlinien für CIRS Eingabe und Auswertung "riskop" (01.04.2021) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Notfallkonzept (27.07.2022) |
| RM05 |
Pain management Pflegerisches Schmerzmanagement (27.04.2021) |
| RM06 |
Fall prophylaxis Handlungskonzept zur Sturzprophylaxe (27.04.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusprophylaxe (27.04.2021) |
| RM08 |
Regulated handling of custodial measures Umgang mit Fixierungen (28.02.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Umgang mit Medizinprodukten (27.04.2021) |
| 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 OP-Sicherheitscheckliste (03.05.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings OP-Sicherheitscheckliste (03.05.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups OP-Sicherheitscheckliste (03.05.2022) |
| RM17 |
Standards for recovery and postoperative care Postoperative Betreuung und Überwachung eines Patienten im AWR (27.04.2021) |
| RM18 |
Discharge management Entlassmanagement (18.05.2022) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Patientenidentifikationsarmband, OP-Checklisten
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.04.2021 |
| 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 bei Bedarf |
Conference committee
Conference frequency: quartalsweise
| 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) |