Dealing with risks in patient care

Quality management

Sarah Theresa Klaus

Qualitätsmanagementbeauftragte

An der Wipper 2
06567 Bad Frankenhausen

Phone: 03634 -52-1532
Mail: ed.nekinilk-gmk@sualK.S

Geschäftsführung, Qualitätsmanagement, Ärztliche Leitung, Betriebsrat, Pflegedienstleitung

Conference frequency: quartalsweise

Risk management

Sarah Theresa Klaus

Qualitätsmanagementbeauftragte

Phone: 03634 -52-1532
Fax: 03634-52-1228
Mail: ed.nekinilk-gmk@sualK.S

Geschäftsführung, Qualitätsmanagement, Ärztliche Leitung, Betriebsrat, Pflegedienstleitung

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

Risikomanagement Handbuch (30.01.2020)

RM02

Regular further education and training measures

RM04

Clinical emergency management

LL_Notfallmanagement (15.05.2023)

RM05

Pain management

VA_Schmerzmanagement (27.03.2023)

RM06

Fall prophylaxis

SOP Sturzprophylaxe (14.11.2022)

RM07

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

Expertenstandard Dekubitusprophylaxe (28.02.2022)

RM09

Regulated handling of occurring malfunctions of devices

VA_Einweisung Medizinprodukte (04.06.2021)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • 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

OP-Statut (22.02.2021)

RM15

Preoperative, complete presentation of necessary findings

OP-Statut (22.02.2021)

RM16

Procedure to avoid procedural and patient mix-ups

OP-Statut (22.02.2021)

RM17

Standards for recovery and postoperative care

VA_Anästhesie Aufwachraum (22.02.2021)

RM18

Discharge management

SOP Patientenentlassung (22.05.2019)

Fault reporting systems

Conference committee

Conference frequency: quartalsweise

Measures

Maßnahmenplanung je nach geschildertem Sachverhalt nach Klassifizierung über Risikomatrix.

No. Explanation
IF01

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

As of: 06.07.2022

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)