Dealing with risks in patient care
Quality management
Christina Kobylinski
Leiterin Qualitäts- und Risikomanagement
Bodelschwinghstraße 10
68723 Schwetzingen
Phone:
06202
-84-653529
Mail:
ed.nrg@iksnilybok.anitsirhc
Geschäftsführung bzw. Geschäftsführersitzung
Conference frequency: quartalsweise
Risk management
Christina Kobylinski
Leiterin Qualitäts- und Risikomanagement
68705 Schwetzingen
Phone:
06202
-84-653529
Mail:
ed.nrg@iksnilybok.anitsirhc
Conference frequency:
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikomanagement-Handbuch (D6263) (28.10.2024) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Krankenhaus Alarm- und Einsatzplan (D2731) mit Notfallmanagement-Konzept (30.07.2024) |
| RM05 |
Pain management 1. Schmerztherapie UCH/ Ortho (D2128) 2. Schmerztherapie Alterstraumatologie (D10534) 3. Schmerztherapie bei Neugeborenen (D2410) 4. Schmerzstandard Notfallambulanz (D9982) 5. Schmerztherapie Neurologie (D10032/ 10033) (29.11.2023) |
| RM06 |
Fall prophylaxis 1. Sturz-Assessment in der digitalen Pflegedokumentation (epaAC/ LEP) 2. Flyer Sturzprophylaxe (1973) 3. Sturzprotokoll (D6330) (13.07.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) 1. Dekubitus- Assessment in der digitalen Pflegedokumentation (epaAC/ LEP) 2. AA Dekubitus (D10162) (26.02.2024) |
| RM09 |
Regulated handling of occurring malfunctions of devices Organisationshandbuch Medizinprodukte (D10210) (26.10.2023) |
| 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 perioperative Sicherheitscheckliste (SpeedPrint) (01.07.2020) |
| RM15 |
Preoperative, complete presentation of necessary findings Checkliste OP-Vorbereitung (D6269) (19.10.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Konzept Patientenidentifikationsband (D7662) (13.10.2024) |
| RM17 |
Standards for recovery and postoperative care 1. Checkliste Aufwachraum (D8129) 2. postoperativer Überwachungsbogen (D7421) (01.08.2023) |
| RM18 |
Discharge management Belegungsmanagement (D7796) (09.08.2023) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
- SOP "Arzneimittelmanagement während Hitzeperiode" - Pflichtfortbildungen in "Basishygiene, Arbeitsschutz und Datenschutz" für alle Mitarbeitenden - Deeskalationstraining nach Vorfall mit paranoid/ schizophrenem Patienten; - Compliance-Begehungen zur Händedesinfektion durch Hygienefachkraft
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 08.10.2024 |
| IF02 |
Internal evaluation of the received reports taken jährlich |
| IF03 |
Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken monatlich |
Conference committee
Conference frequency: jährlich
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |