Dealing with risks in patient care

Quality management

Ulrich Kiefer

Qualitäts- u. Risikomanager

Trierer Straße 148
66663 Merzig

Phone: 06861 -705-1627
Mail: ed.nekinilk-ghs.gzm@refeik.u

Qualitäts-/Risikomanager Ärztlicher Direktor u. Stellvertreter Pflegedirektor u. Stellvertreterin Verwaltungsdirektor

Conference frequency: wöchentlich

Risk management

Ulrich Kiefer

Qualitäts- u. Risikomanager

Phone: 06861 -705-1627
Fax: 06861-705-1810
Mail: ed.nekinilk-ghs.gzm@refeik.u

Qualitäts-/Risikomanager Ärztlicher Direktor u. Stellvertreter Pflegedirektor u. Stellvertreterin Verwaltungsdirektor

Conference frequency: wöchentlich

Risk management instruments and measures

No. Explanation
RM01

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

QM u. RM Dokumentenlenkungssystem "Nexus-Curator" (11.10.2024)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

VA - Internes Notfallmanagement (11.10.2024)

RM05

Pain management

Expertenstandard "Akuter Schmerz" (11.10.2024)

RM06

Fall prophylaxis

Expertenstandard "Sturzphrophylaxe" (11.10.2024)

RM07

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

Dekubitusprophylaxe in der Pflege auf Grundlage des nationalen Expertenstandards nach DNQP (11.10.2024)

RM08

Regulated handling of custodial measures

SOP - Vorgehen bei Unterbringungen und freiheitsentziehenden Maßnahmen (02.04.2024)

RM09

Regulated handling of occurring malfunctions of devices

Organisationshandbuch Medizintechnik (11.10.2024)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Palliativbesprechungen
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

WHO angelehnte OP-Sicherheits-Checkliste (31.05.2024)

RM15

Preoperative, complete presentation of necessary findings

WHO angelehnte OP-Sicherheits-Checkliste (31.05.2024)

RM16

Procedure to avoid procedural and patient mix-ups

WHO angelehnte OP-Sicherheits-Checkliste (31.05.2024)

RM17

Standards for recovery and postoperative care

Behandlung im Aufwachraum (11.10.2024)

RM18

Discharge management

Expertenstandard "Entlassmanagement" (11.10.2024)

Fault reporting systems

Conference committee

Conference frequency: bei Bedarf

Measures

Softwaregestützte Erfassung von Beinahe-Vorkommnissen

No. Explanation
IF01

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

As of: 05.10.2023

IF02

Internal evaluation of the received reports

taken bei Bedarf

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: bei Bedarf

No. Explanation
EF03

KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association)