Dealing with risks in patient care
Quality management
Gudrun Konnerth
Leitung Qualitätsmanagement
Robert-Koch-Straße 1
84034 Landshut
Phone:
0871
-698-3635
Mail:
ed.tuhsdnal-mukinilk@tnemeganamsteatilauq
Martin Wilke
Leitung Qualitätsmanagement
Robert-Koch-Straße 1
84034 Landshut
Phone:
0871
-698-13635
Mail:
ed.tuhsdnal-mukinilk@tnemeganamsteatilauq
QM Steuergruppe mit QMB Pflege, QMB Ärzte, QMB Verwaltung, zentrales QM, kRM, Betriebsrat
Conference frequency: quartalsweise
Risk management
Gudrun Konnerth
Leitung Qualitätsmanagement
Phone:
0871
-698-3635
Fax: 0871-698-3634
Mail:
ed.tuhsdnal-mukinilk@tnemeganamsteatilauq
Susanne Ecker
Klinische Risikomanagerin
Phone:
0871
-698-3742
Fax: 0871-698-3634
Mail:
ed.tuhsdnal-mukinilk@rekce.ennasus
QM Steuergruppe mit QMB Pflege, QMB Ärzte, QMB Verwaltung, zentrales QM, kRM, Betriebsrat
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available z. B. Dienstanweisung klinisches Risikomanagement (10.08.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management SOP Innerklinischer Notfall (09.06.2020) |
| RM05 |
Pain management z.B. Expertenstandard akuter Schmerz (12.04.2023) |
| RM06 |
Fall prophylaxis Expertenstandard Sturzprophylaxe (14.06.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Sturzprophylaxe (14.06.2023) |
| RM08 |
Regulated handling of custodial measures Verfahrensanweisung zur Durchführung freiheitsentziehender Maßnahmen (FeM) (24.04.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Fehlermanagement (16.06.2021) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| 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 z.B. Patientenorientiertes Blutmanagement (04.05.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings z.B. Perioperatives Management (24.04.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Sicherheits-Checkliste für operative Eingriffe / Verfahrensanweisung nach WHO (13.12.2022) |
| RM17 |
Standards for recovery and postoperative care z. B. Sicherheits-Checkliste für operative Eingriffe / Verfahrensanweisung nach WHO (13.12.2022) |
| RM18 |
Discharge management Entlassmanagement (17.11.2022) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Aufrüstung von AED, Mitarbeiterschulungen, Aufrüstung Notfallwagen, Erstellung von SOP, Aufrüstung Liegen ZNA, Einführung NRFit System Intensivstation, Aufrüstung Brandschutztüre mit Magnethalterung.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 19.07.2023 |
| 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 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) |