Dealing with risks in patient care

Quality management

Steve Jordan

Qualitätsmanagementbeauftragter

Robert-Koch-Straße 3
34376 Immenhausen

Phone: 05673 -501-3050
Mail: ed.nesuahnemmi-kinilkhcafnegnul@nadroj.s

Nicole Dittrich

Qualitätsmanagementbeauftragte

Robert-Koch-Straße 3
34376 Immenhausen

Phone: 05673 -501-1620
Mail: ed.nesuahnemmi-kinilkhcafnegnul@hcirttid.n

Geschäftsführung, Ärztlicher Leiter, Pflegedienstleitung, CT/Röntgen, Lungenfunktion, Endoskopie, Sozialdienst, Küche, Physiotherapie, Hauswirtschaft, Haustechnik, EDV, Personalabteilung, Patientenverwaltung, Controlling

Conference frequency: andere Frequenz

Risk management

Steve Jordan

Qualitätsmanagementbeauftragter

Phone: 05673 -501-3050
Mail: ed.nesuahnemmi-kinilkhcafnegnul@nadroj.s

Nicole Dittrich

Qualitätsmanagementbeauftragte

Phone: 05673 -501-1620
Mail: ed.nesuahnemmi-kinilkhcafnegnul@hcirttid.n

Geschäftsführung, Ärztlicher Leiter, Pflegedienstleitung, CT/Röntgen, Lungenfunktion, Endoskopie, Sozialdienst, Küche, Physiotherapie, Hauswirtschaft, Haustechnik, EDV, Personalabteilung, Patientenverwaltung, Controlling

Conference frequency: andere Frequenz

Risk management instruments and measures

No. Explanation
RM01

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

QM-Handbuch (04.04.2019)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

QM-Handbuch (04.04.2019)

RM05

Pain management

QM-Handbuch (04.04.2019)

RM06

Fall prophylaxis

QM-Handbuch (04.04.2019)

RM07

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

QM-Handbuch (04.04.2019)

RM08

Regulated handling of custodial measures

QM-Handbuch (04.04.2019)

RM09

Regulated handling of occurring malfunctions of devices

QM-Handbuch (04.04.2019)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Pathologiebesprechungen
  • Palliativbesprechungen
RM12

Use of standardised information sheets

RM13

Application of standardised surgical check lists

RM16

Procedure to avoid procedural and patient mix-ups

QM-Handbuch (04.04.2019)

RM17

Standards for recovery and postoperative care

QM-Handbuch (04.04.2019)

RM18

Discharge management

QM-Handbuch (04.04.2019)

Fault reporting systems

Conference committee

Conference frequency: jährlich

Measures

Aushändigung von Patientenidentifikationsbändern bei Aufnahme, Implementierung einer„Fehlersammelkarte“ im Funktionsbereich Lungenfunktion (weitere Funktionsbereiche in Planung), Durchführung von FMEA in allen relevanten Funktionsbereichen in Planung

No. Explanation
IF01

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

As of: 04.04.2019

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: andere Frequenz

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)