Dealing with risks in patient care

Quality management

Melanie Kolkhorst

Qualitätsmanagement

Marie-Hackfeld-Straße 6
27211 Bassum

Phone: 05441 -972130-
Mail: ed.dkl-nekinilk@tsrohklok.m

QM-Abteilung, Geschäftsführung

Conference frequency: monatlich

Risk management

Melanie Kolkhorst

Qualitätsmanagement

Marie-Hackfeld-Straße 6
27211 Bassum

Phone: 05441 -972130-
Mail: ed.dkl-nekinilk@tsrohklok.m

Ärztlicher Dienst (Innere Medizin, Chirurgie), Funktionsdienst, Pflege Somatik, Pflege Psychiatrie, Qualitätsmanagement

Conference frequency: bei Bedarf

Risk management instruments and measures

No. Explanation
RM02

Regular further education and training measures

RM04

Clinical emergency management

Notfallhandbuch (01.10.2021)

RM05

Pain management

VA Schmerz (VA-PD-007) (01.04.2022)

RM06

Fall prophylaxis

VA Sturzprophylaxe (VA-PD-008) (01.07.2021)

RM07

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

VA Dekubitusprophylaxe (VA-PD-003) (01.07.2021)

RM08

Regulated handling of custodial measures

VA Fixierung (VA-PD-006) (01.03.2020)

RM09

Regulated handling of occurring malfunctions of devices

HB-MT-001 Orga-Handbuch Medizintechnik (01.09.2021)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Mortalitäts- und Morbiditätskonferenzen
RM12

Use of standardised information sheets

RM13

Application of standardised surgical check lists

RM15

Preoperative, complete presentation of necessary findings

OP-Sicherheitscheckliste Sign In (CL-OP-001) (01.10.2021)

RM16

Procedure to avoid procedural and patient mix-ups

VA OP-Sicherheitscheckliste (VA-OP-001) (01.10.2021)

RM17

Standards for recovery and postoperative care

SOPs Standardmappe Anästhesiepflege (01.05.2021)

RM18

Discharge management

VA Entlassmanagement (VA-KV-006) (01.04.2022)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Einführung eines MTS-Systems

No. Explanation
IF01

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

As of: 01.04.2022

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 bei Bedarf

Conference committee

Conference frequency: