Dealing with risks in patient care

Quality management

Herr Christian Ponocny

Qualitätsmanager

Steinbecker Straße 44
21244 Buchholz in der Nordheide

Phone: 04171 -13-4004
Mail: ed.nesniw-suahneknark@ynconop.naitsirhc

QM-Steuergruppe

Conference frequency: quartalsweise

Risk management

Christian Ponocny

Qualitätsmanager

Steinbecker Straße 44
21244 Buchholz in der Nordheide

Phone: 04171 -13-4004
Fax: 04171-13-4029
Mail: ed.nesniw-suahneknark@ynconop.naitsirhc

QM-Steuergruppe

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

QM-Handbuch (20.10.2021)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

QM-Handbuch (20.10.2021)

RM05

Pain management

In der jeweiligen Fachabteilung (20.10.2021)

RM06

Fall prophylaxis

QM-Handbuch (20.10.2021)

RM07

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

QM-Handbuch (20.10.2021)

RM08

Regulated handling of custodial measures

QM-Handbuch (20.10.2021)

RM09

Regulated handling of occurring malfunctions of devices

QM-Handbuch (20.10.2021)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Palliativbesprechungen
  • Qualitätszirkel
  • geriatrische Besprechungen
  • Klinisches Etik Kommitee (KEK)
  • Corona-Sitzungen
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

QM-Handbuch (20.10.2021)

RM15

Preoperative, complete presentation of necessary findings

QM-Handbuch (20.10.2021)

RM16

Procedure to avoid procedural and patient mix-ups

QM-Handbuch (20.10.2021)

RM17

Standards for recovery and postoperative care

QM-Handbuch (20.10.2021)

RM18

Discharge management

QM-Handbuch (20.10.2021)

Fault reporting systems

Conference committee

Conference frequency: quartalsweise

Measures

Einführung von Patientenarmbändern CIRS-System M+M Konferenzen Fachübergreifende Qualitätszirkel Regelmäßige interne Audits

No. Explanation
IF01

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

As of: 18.10.2021

IF02

Internal evaluation of the received reports

taken quartalsweise

IF03

Training of employees in handling the error reporting system and in implementing the findings from the error reporting system

taken quartalsweise

Conference committee

Conference frequency: quartalsweise

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)