To the hospital’s home page

Klinikum Kulmbach

Dealing with risks in patient care

Quality management

Responsible person

Dr. Susanne Luber

Qualitätsmanagementbeauftragte

Albert-Schweitzer-Straße 10
95326 Kulmbach

Phone: 09221 -98-5009
Mail: ed.hcabmluk-mukinilk@rebuL.ennasuS

Steering committee

Zur regelmäßigen Pflege und Fortentwicklung des QM-Systems werden die Oberste Leitung (Geschäftsführung) und die beiden QMBs durch weitere Mitarbeiter unterstützt, die über besondere Kenntnisse und Fähigkeiten verfügen.

Conference frequency: bei Bedarf

Risk management

Responsible person

Matthias Zehe

Externer Risikomanagementbeauftragter

Phone: 09221 -98-5000
Fax: 09221-98-5044
Mail: ed.hcabmluk-mukinilk@gnurheufstfeahcseg

Steering committee

Conference frequency: bei Bedarf

Risk management instruments and measures

Instruments and measures

No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available DIN EN ISO 9001:2015, ISO 31000 / ONR 49000 ff (31.10.2020)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management DIN EN ISO 9001:2015, ISO 31000 / ONR 49000 ff (31.10.2020)
RM05	Pain management DIN EN ISO 9001:2015, ISO 31000 / ONR 49000 ff (31.10.2020)
RM06	Fall prophylaxis DIN EN ISO 9001:2015, ISO 31000 / ONR 49000 ff (31.10.2020)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) DIN EN ISO 9001:2015, ISO 31000 / ONR 49000 ff (31.10.2020)
RM08	Regulated handling of custodial measures DIN EN ISO 9001:2015, ISO 31000 / ONR 49000 ff (31.10.2020)
RM09	Regulated handling of occurring malfunctions of devices DIN EN ISO 9001:2015, ISO 31000 / ONR 49000 ff (31.10.2020)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Pathologiebesprechungen 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 DIN EN ISO 9001:2015, ISO 31000 / ONR 49000 ff (31.10.2020)
RM15	Preoperative, complete presentation of necessary findings DIN EN ISO 9001:2015, ISO 31000 / ONR 49000 ff (31.10.2020)
RM16	Procedure to avoid procedural and patient mix-ups DIN EN ISO 9001:2015, ISO 31000 / ONR 49000 ff (31.10.2020)
RM17	Standards for recovery and postoperative care DIN EN ISO 9001:2015, ISO 31000 / ONR 49000 ff (31.10.2020)
RM18	Discharge management DIN EN ISO 9001:2015, ISO 31000 / ONR 49000 ff (31.10.2020)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: bei Bedarf

Measures

CIRS Meldesystem für Zwischenfälle und Beinahe-Zwischenfälle. M+M-Konferenzen (hausweit und zentrumsspezifisch).

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 21.08.2020
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

No.

Explanation

IF01

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

As of: 21.08.2020

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

Across all institutions

Conference committee

Conference frequency: