Dealing with risks in patient care

Quality management

Karin vom Holt

Qualitätsmanagementbeauftragte

Klostenstrasse 19
77933 Lahr

Phone: 0781 -472-4950
Mail: ed.mukinilk-uanetro@tnemeganamsteatilauq

3 Mitarbeitende aus dem Ärztlichen Dienst, 2 Mitarbeitende aus dem Pflegedienst, 2 Mitarbeitende aus dem Verwaltungsdienst

Conference frequency: andere Frequenz

Risk management

Karin vom Holt

Qualitätsmanagementbeauftragte

Klostenstraße 19
77931 Lahr

Phone: 0781 -472-4950
Fax: 0781-472-4902
Mail: ed.mukinilk-uanetro@tnemeganamsteatilauq

Ärztlicher Vorstand, Pflegerische Vorständin, Mitarbeitende aus dem Risikomanagements

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

Risikopolitik; Konzept zum Risikomanagement (24.06.2022)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Cardiopulmonale Reanimation und Organisation des CPR-Teams (01.09.2021)

RM05

Pain management

VA Schmerzmanagement (11.03.2019)

RM06

Fall prophylaxis

VA Sturzmanagement (24.08.2022)

RM07

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

VA Dekubitusmanagement (24.08.2022)

RM08

Regulated handling of custodial measures

VA ZEN Zwangsmaßnahmen (30.07.2021)

RM09

Regulated handling of occurring malfunctions of devices

Dienstanweisung für den Betrieb von aktiven, nicht implantierbaren Medizinprodukten (12.02.2023)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Pathologiebesprechungen
  • Palliativbesprechungen
  • Interdisziplinäres angiologisches Kolloquium
  • Interdisziplinäre Mammakonferenz
  • etc.
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

VA OP-Vorbereitung (13.09.2018)

RM16

Procedure to avoid procedural and patient mix-ups

Checkliste Schleußenvorgang, OP-Checkliste (21.12.2020)

RM17

Standards for recovery and postoperative care

VA Post-OP (18.10.2018)

RM18

Discharge management

Prozess Entlassmanagement (15.09.2019)

Fault reporting systems

Conference committee

Conference frequency: quartalsweise

Measures

Etablierung des Konzeptes "STOP-CHECK-INJEKT"

No. Explanation
IF01

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

As of: 07.07.2022

IF02

Internal evaluation of the received reports

taken monatlich

IF03

Training of employees in handling the error reporting system and in implementing the findings from the error reporting system

taken monatlich

Conference committee

Conference frequency: bei Bedarf

No. Explanation

Other

EF03

KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors)