Dealing with risks in patient care

Quality management

Sina Piatkowski

QMB

Feldstrasse 1
27793 Wildeshausen

Phone: 04431 -9829080-0
Mail: ed.muennahoj-suahneknark@bmq

Krankenhausdirektorium, QM/RM

Conference frequency: monatlich

Risk management

Sina Piatkowski

QMB

Feldstrasse 1
27793 Wildeshausen

Phone: 04431 -9829080-0
Mail: ed.muennahoj-suahneknark@bmq

Krankenhausdirektorium, QM/RM

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

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

Geschäftsordnung riskop im Johanneum (15.01.2021)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Geschäftsordnung riskop im Johanneum (15.01.2021)

RM05

Pain management

Geschäftsordnung riskop im Johanneum (15.01.2021)

RM06

Fall prophylaxis

Geschäftsordnung riskop im Johanneum (15.01.2021)

RM07

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

Geschäftsordnung riskop im Johanneum (15.01.2021)

RM08

Regulated handling of custodial measures

Geschäftsordnung riskop im Johanneum (15.01.2021)

RM09

Regulated handling of occurring malfunctions of devices

Geschäftsordnung riskop im Johanneum (15.01.2021)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
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 (17.03.2023)

RM15

Preoperative, complete presentation of necessary findings

Geschäftsordnung riskop im Johanneum (15.01.2021)

RM16

Procedure to avoid procedural and patient mix-ups

Geschäftsordnung riskop im Johanneum (15.01.2021)

RM17

Standards for recovery and postoperative care

Geschäftsordnung riskop im Johanneum (15.01.2021)

RM18

Discharge management

Geschäftsordnung riskop im Johanneum (15.01.2021)

Fault reporting systems

Conference committee

Conference frequency: wöchentlich

Measures

2.2.1.7 AB Zwischenfallmanagement - CIRS

No. Explanation
IF01

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

As of: 28.03.2023

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 bei Bedarf

Conference committee

Conference frequency: