Dealing with risks in patient care

Quality management

Peter Plattner

Leiter integrierte Managementsysteme

Graneckerstraße 1
94036 Passau

Phone: 08541 -206760-
Mail: ed.uassap-eg@renttalpp

Patricia Zückert

Leiterin integrierte Managementsysteme

Graneckerstraße 1
94036 Passau

Phone: 08541 -206760-
Mail: ed.uassap-eg@ofni

GeschäftsführungÄrztlicher LeiterVerwaltungsleiterPflegedienstleiterLeiter integrierte ManagementsystemeLeiter externe Kommunikation

Conference frequency: wöchentlich

Risk management

Peter Plattner

Leiter integrierte Managementsysteme

Graneckerstraße 1
94036 Passau

Phone: 08541 -206760-
Mail: ed.uassap-eg@renttalpp

Patricia Zückert

Leiterin integrierte Managementsysteme

Graneckerstraße 1
94036 Passau

Phone: 08541 -206760-
Mail: ed.uassap-eg@ofni

GeschäftsführungÄrztlicher LeiterVerwaltungsleiterPflegedienstleiterLeiter integrierte ManagementsystemeLeiter externe Kommunikation

Conference frequency: wöchentlich

Risk management instruments and measures

No. Explanation
RM01

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

Geschäftsordnung (14.05.2020)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Verfahren Klinisches Notfallmanagement (23.07.2020)

RM05

Pain management

Standard Schmerztheraphie (01.06.2021)

RM06

Fall prophylaxis

Prozess-Standard Sturzprävention (27.10.2020)

RM07

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

Prozess-Standard Dekubitus-Prävention (29.07.2020)

RM08

Regulated handling of custodial measures

Prozess-Standard Patientenfixierung (15.04.2020)

RM09

Regulated handling of occurring malfunctions of devices

MPG-Rechte+Pflichten für Geräteanwender (21.05.2021)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Risk Kernteam
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-Checkliste (21.05.2021)

RM15

Preoperative, complete presentation of necessary findings

WHO-Checkliste (21.05.2021)

RM16

Procedure to avoid procedural and patient mix-ups

WHO-Checkliste (21.05.2021)

RM17

Standards for recovery and postoperative care

OP-Nachsorge (28.07.2020)

RM18

Discharge management

Prozess Entlassung (12.03.2020)

Fault reporting systems

Conference committee

Conference frequency: wöchentlich

Measures

Überarbeitung der Behandlungspfade

No. Explanation
IF01

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

As of: 08.01.2020

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 jährlich

Conference committee

Conference frequency: wöchentlich

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)