Dealing with risks in patient care

Quality management

Dr. med. Alexandra Ebert

Qualitätsmanagement

Steinerweg 5
81241 München

Phone: 089 -8892-2615
Mail: ed.tiehdnuseg-soileh@3trebe.ardnaxela

Conference frequency:

Risk management

Reza Ghotbi

Ärztlicher Direktor

Phone: 089 -8892-2628
Fax: 089-8892-2958
Mail: ed.tiehdnuseg-soileh@ibtohg.azer

Conference frequency:

Risk management instruments and measures

No. Explanation
RM01

Comprehensive quality and/or risk management documentation (QM/RM documentation) is available

QM und RM (zentrales Dokumentationsverzeichnis) (29.09.2023)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Verfahrensbeschreibungen im Rahmen der Rezertifizierung als regionales Traumazentrum (12.01.2022)

RM05

Pain management

Handlungsempfehlung Schmerzmanagement in der Pflege bei akuten und chronischen Schmerzen (01.09.2019)

RM06

Fall prophylaxis

Beschluss der FG Pflege Sturzprophylaxe (01.02.2023)

RM07

Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”)

Beschluss der FG Pflege Dekubitusprophylaxe (01.11.2021)

RM08

Regulated handling of custodial measures

VA Freiheitsentziehende Maßnahmen (26.08.2014)

RM09

Regulated handling of occurring malfunctions of devices

Verfahrensstandard Umgang mit Produktproblemen (ZD Einkauf) (29.05.2015)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Palliativbesprechungen
  • Qualitätszirkel
  • OP-Indikationskonferenzen
  • Peer-Reviews
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

Konzernregelung OP-Sicherheit (27.01.2022)

RM15

Preoperative, complete presentation of necessary findings

Konzernregelung OP-Sicherheit (27.01.2022)

RM16

Procedure to avoid procedural and patient mix-ups

Konzernregelung OP-Sicherheit (27.01.2022)

RM17

Standards for recovery and postoperative care

NEWS vor Verlegung/ Wissensziel 2019 (02.03.2017)

RM18

Discharge management

VA ärztliches Entlaßmanagement (23.07.2019)

Fault reporting systems

Conference committee

Conference frequency: halbjährlich

Measures

erfolgreiche Steigerung der Meldefrequenz, Maßnahmen zur Verbesserung der hausinternen Kommunikation per E-Mail und Hausmitteilung, Verbesserungen des Bettenumlaufs und der Bettenbeschaffung

No. Explanation
IF01

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

As of: 01.12.2016

IF02

Internal evaluation of the received reports

taken halbjährlich

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: halbjährlich

No. Explanation
EF02

CIRS Berlin (Medical Association Berlin, German Medical Association, National Association of Statutory Health Insurance Doctors)

EF03

KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors)