Dealing with risks in patient care

Quality management

Dipl. Pflw. (FH) Anne Panzer

Allg. Qualitätsmanagement

Am Boltenhof 7
46325 Borken

Phone: 02861 -97-1480
Mail: ed.lmwk@reznap.enna

Mitglieder der KBL, MAV, QM und Vertreter aus den Abteilungen/ Funktionsbereichen

Conference frequency: halbjährlich

Risk management

Anne Panzer

Allg. Qualitätsmanagement

Phone: 02861 -97-1480
Mail: ed.lmwk@reznap.enna

Mitglieder der KBL, MAV, QM und Vertreter aus den Abteilungen/ Funktionsbereichen

Conference frequency: halbjährlich

Risk management instruments and measures

No. Explanation
RM01

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

Teil der QM/RM Dokumentation (31.12.2021)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Teil der QM/RM Dokumentation (31.12.2021)

RM05

Pain management

Teil der QM/RM Dokumentation (31.12.2021)

RM06

Fall prophylaxis

Teil der QM/RM Dokumentation (31.12.2021)

RM07

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

Teil der QM/RM Dokumentation (31.12.2021)

RM08

Regulated handling of custodial measures

Teil der QM/RM Dokumentation (31.12.2021)

RM09

Regulated handling of occurring malfunctions of devices

Teil der QM/RM Dokumentation (31.12.2021)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • interdisziplinäre Fallbesprechungen im Rahmen von Zentren
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

Teil der QM/RM Dokumentation (31.12.2021)

RM15

Preoperative, complete presentation of necessary findings

Teil der QM/RM Dokumentation (31.12.2021)

RM16

Procedure to avoid procedural and patient mix-ups

Teil der QM/RM Dokumentation (31.12.2021)

RM17

Standards for recovery and postoperative care

Teil der QM/RM Dokumentation (31.12.2021)

RM18

Discharge management

Teil der QM/RM Dokumentation (31.12.2021)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

- Anwendung Patientenidentifikationsarmband- OP- Sicherheitschecklisten- Vertiefung und Erweiterung Cirs- medical- Aufbau/ Ausbau Intranet- Maßnahmen zur Arzneimitteltherapiesicherheit- Risikoaudits Apotheke- Maßnahmenableitungen aus Befragungen- Auswertung ext. QS- Bögen- Bekanntmachung Quick Alert, Rufdienst in der Chirurgie

No. Explanation
IF01

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

As of: 31.12.2021

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: monatlich

No. Explanation

Other

EF01

CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association, National Association of Statutory Health Insurance Doctors)

EF03

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