Dealing with risks in patient care
Quality management
Frau Dr. med. Antje Hoffmann
Ärztliche Direktion
Manskestraße 22
31275 Lehrte
Phone:
05132
-503-107
Mail:
ed.hrk@nnamffoh.ejtna
Regelhaft: -Direktorium -Chefärzte -Bereichsleitungen -Fachabteilungen -QMB's der Standorte -QM-Multiplikatoren
Conference frequency: quartalsweise
Risk management
Antje Hoffmann
Ärztliche Direktion
Manskestraße 22
31275 Lehrte
Phone:
05132
-503-107
Fax: 05132-503-106
Mail:
ed.hrk@nnamffoh.ejtna
Regelhaft: -Direktorium -Chefärzte -Bereichsleitungen -Fachabteilungen -QMB's der Standorte -QM-Multiplikatoren
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Dokumentenlenkungssystem (DLS) (09.08.2023) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Dokumentenlenkungssystem (DLS) (09.08.2023) |
| RM05 |
Pain management Dokumentenlenkungssystem (DLS) (09.08.2023) |
| RM06 |
Fall prophylaxis Pflegestandards Sturzprophylaxe (06.11.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) KRH Pflegestandards Dekubitusprophylaxe, Expertenstandard (25.07.2024) |
| RM08 |
Regulated handling of custodial measures Verfahrensanweisung Freiheitsentziehende Maßnahmen (20.05.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Verfahrensanweisung Umgang mit Medizintechnik (19.06.2024) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| 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 Dokumentenlenkungssystem (DLS) (09.08.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings Dokumentenlenkungssystem (DLS) (09.08.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Dokumentenlenkungssystem (DLS) (09.08.2023) |
| RM17 |
Standards for recovery and postoperative care Dokumentenlenkungssystem (DLS) (09.08.2023) |
| RM18 |
Discharge management Prozessbeschreibung Entlassungsmanagement (25.07.2024) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Konzernweites, webbasiertes CIRS
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 15.11.2022 |
| 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: bei Bedarf
| No. | Explanation |
|---|---|
|
Other |