Carl-von-Basedow-Klinikum Saalekreis gGmbH

Dealing with risks in patient care

Quality management

Dr. med. Jule Wenke Winkler

Leitung Qualitätsmanagement/ Krankenhaushygiene

Vor dem Nebraer Tor 11
06268 Querfurt

Phone: 03461-27-1007
Mail: ed.sierkelaas-mukinilk@relkniw.wj

Qualitätskommission bestehend aus: Geschäftsführer, Prokurist, Ärztlicher Direktor, Pflegedienstdirektorin, Pflegebereichsleitung, Vertreter Betriebsrat, Leitung Hygiene und Qualitätsmanagement, Qualitätsbeauftragte, Qualitätsmanagerin, Strategisches Controlling und Unternehmensentwicklung

Conference frequency: quartalsweise

Risk management

Vor dem Nebraer Tor 11
06268 Querfurt

Phone: --

Qualitätskommission bestehend aus: Geschäftsführer, Prokurist, Ärztlicher Direktor, Pflegedienstdirektorin, Pflegebereichsleitung, Vertreter Betriebsrat, Leitung Hygiene und Qualitätsmanagement, Qualitätsbeauftragte, Qualitätsmanagerin, Strategisches Controlling und Unternehmensentwicklung

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

Intranet (01.11.2016)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Intranet (01.11.2016)

RM05

Pain management

Intranet (01.11.2016)

RM06

Fall prophylaxis

Intranet (01.11.2016)

RM07

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

Intranet (01.11.2016)

RM08

Regulated handling of custodial measures

Intranet (01.11.2016)

RM09

Regulated handling of occurring malfunctions of devices

DMS Roxtra (01.11.2014)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Palliativbesprechungen
  • Qualitätszirkel
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

Intranet (01.11.2016)

RM15

Preoperative, complete presentation of necessary findings

Intranet (01.11.2016)

RM16

Procedure to avoid procedural and patient mix-ups

Intranet (01.11.2016)

RM18

Discharge management

Intranet (01.11.2016)

Fault reporting systems

Conference committee

Conference frequency: bei Bedarf

Measures

CIRS-Meldungen Einsatz von Patientenidentifikationsarmbändern POCT-Geräte M & M Konferenzen


No. Explanation
IF01

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

As of: 28.01.2021

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 Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors)