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Kliniken Dr. Erler gGmbH

Dealing with risks in patient care

Quality management

Responsible person

Jürgen Grieß

Leitung Qualitäts- und Risikomanagement

Kontumazgarten 4-19
90429 Nürnberg

Phone: 0911 -2728-546
Mail: ed.kinilk-relre@tnemeganamsteatilauq

Steering committee

2 Mitarbeiter Ärztlicher Dienst, 2 Mitarbeiter Pflegedienst, 3 Mitarbeiter Funktionsdienst, 1 Mitarbeiter Administrativer Bereich, 1 Mitarbeiter Verwaltung, Qualitätsmanagementbeauftragter, Risikomanagementbeauftragter

Conference frequency: quartalsweise

Risk management

Responsible person

Holger König

Leitung Qualitäts- und Risikomanagement

Kontumazgarten 4-19
90429 Nürnberg

Phone: 0911 -2728-447
Fax: 0911-2728-846
Mail: ed.kinilk-relre@tnemeganamsteatilauq

Jürgen Grieß

Leitung Qualitäts- und Risikomanagement

Kontumazgarten 4-19
90429 Nürnberg

Phone: 0911 -2728-546
Fax: 0911-2728-846
Mail: ed.kinilk-relre@tnemeganamsteatilauq

Steering committee

Conference frequency: quartalsweise

Risk management instruments and measures

Instruments and measures

No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitätsmanagementhandbuch und Risikomanagementhandbuch (23.12.2022)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Qualitätsmanagementhandbuch und Risikomanagementhandbuch (23.12.2022)
RM05	Pain management Qualitätsmanagementhandbuch und Risikomanagementhandbuch (23.12.2022)
RM06	Fall prophylaxis Qualitätsmanagementhandbuch und Risikomanagementhandbuch (23.12.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Qualitätsmanagementhandbuch und Risikomanagementhandbuch (23.12.2022)
RM08	Regulated handling of custodial measures Qualitätsmanagementhandbuch und Risikomanagementhandbuch (23.12.2022)
RM09	Regulated handling of occurring malfunctions of devices Qualitätsmanagementhandbuch und Risikomanagementhandbuch (23.12.2022)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Ethische Fallbesprechungen
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 Qualitätsmanagementhandbuch und Risikomanagementhandbuch (23.12.2022)
RM15	Preoperative, complete presentation of necessary findings Qualitätsmanagementhandbuch und Risikomanagementhandbuch (23.12.2022)
RM16	Procedure to avoid procedural and patient mix-ups Qualitätsmanagementhandbuch und Risikomanagementhandbuch (23.12.2022)
RM17	Standards for recovery and postoperative care Qualitätsmanagementhandbuch und Risikomanagementhandbuch (23.12.2022)
RM18	Discharge management Qualitätsmanagementhandbuch und Risikomanagementhandbuch (23.12.2022)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Weiterentwicklung diverser Arbeits- und Prozessabläufe sowie der entsprechenden Vorgabedokumente (Aufnahme, operative Behandlung, Entlassung etc.); Schulung und Sensibilisierung der Mitarbeiter zur Gewährleistung der sicheren Patientenidentifikation (Daten-Check, Markierung OP-Gebiet, Team-Time-Out etc.) und zum Medikamentenmanagement (6-R-Regel, 4-Augen-Prinzip etc.); Optimierung der Struktur, Workflows und Nachvollziehbarkeit der elektronischen Patientenakte

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 18.01.2022
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

No.

Explanation

IF01

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

As of: 18.01.2022

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

Across all institutions

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)