Dealing with risks in patient care

Quality management

Dipl. med. Heimo Dünzel

OA Anästhesie, QMB

Horkaer Straße 15-21
02929 Rothenburg

Phone: 035891 -42-284
Mail: ed.grubnehtor-kinilk@lezneud.omieh

Geschäftsführung, Ärztlicher Dienst, Pflegedienst, Verwaltungsdienst, Mitarbeitervertretung, Leiter EndoProthetikZentrum, Koordinator EndoProthetikZentrum, QMB EndoProtetikZentrum

Conference frequency: halbjährlich

Risk management

Sarah Klawuhn

Hygienefachkraft

Horkaer Straße 15-21
02929 Rothenburg

Phone: 035891 -42-219
Mail: ed.grubnehtor-kinilk@nhuwalk.haras

Hygienefachkraft, Ärztlicher Dienst, Abteilung Technik

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

Dienstanweisung (26.10.2022)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Dienstanweisung (19.05.2022)

RM05

Pain management

Dienstanweisung (30.09.2022)

RM06

Fall prophylaxis

Dienstanweisung (21.10.2022)

RM07

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

Pflegestandard (23.01.2023)

RM08

Regulated handling of custodial measures

Pflegestandard (26.01.2023)

RM09

Regulated handling of occurring malfunctions of devices

Dienstanweisung (25.10.2022)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Komplikationsbesprechung im Rahmen des Endoprothetikzentrums sowie Teambesprechung Multimodale Schmerztherapie
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

Dienstanweisung (27.10.2022)

RM15

Preoperative, complete presentation of necessary findings

Dienstanweisung (07.06.2022)

RM16

Procedure to avoid procedural and patient mix-ups

Dienstanweisung (27.10.2022)

RM17

Standards for recovery and postoperative care

Dienstanweisung (30.09.2022)

RM18

Discharge management

Dienstanweisung (15.10.2020)

Fault reporting systems

Conference committee

Conference frequency: quartalsweise

Measures

Aktualisierung Konzept Patientensicherheit, Anpassung des Patientenbriefes "Stationäre Aufnahme"

No. Explanation
IF01

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

As of: 26.10.2022

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 quartalsweise

Conference committee

Conference frequency: