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AGAPLESION EV. KLINIKUM SCHAUMBURG

Dealing with risks in patient care

Quality management

Responsible person

Guido Köhler

Qualitätsmanagementbeauftragte

Zum Schaumburger Klinikum 1
31683 Obernkirchen

Phone: 05724 -9580-1426
Mail: ed.noiselpaga@relheok.odiug

Steering committee

- Krankenhausleitungssitzung (Lenkungsgremium) - Jour Fixe mit der Geschäftsführung - Gesamtbetriebsleitersitzungen - vierteljährlich AGAPLESION Arbeitsbereich QM (XB PQM) Treffen aller Qualitätsmanagementbeauftragten konzernweit - Vierteljährliches Treffen der QMB im Weserbergland-Cluster

Conference frequency: monatlich

Risk management

Responsible person

Guido Köhler

Qualitätsmanagementbeauftragte

Phone: 05724 -9580-1426
Fax: 05724-9580-1009
Mail: ed.noiselpaga@relheok.odiug

Steering committee

Conference frequency: monatlich

Risk management instruments and measures

Instruments and measures

No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available AGA Qualitäts- und Risikomanagement (31.07.2019)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management AGA Qualitäts- und Risikomanagement (31.07.2019)
RM05	Pain management AGA Qualitäts- und Risikomanagement (31.07.2019)
RM06	Fall prophylaxis AGA Qualitäts- und Risikomanagement (31.07.2019)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) AGA Qualitäts- und Risikomanagement (31.07.2019)
RM08	Regulated handling of custodial measures AGA Qualitäts- und Risikomanagement (31.07.2019)
RM09	Regulated handling of occurring malfunctions of devices AGA Qualitäts- und Risikomanagement (31.07.2019)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Palliativbesprechungen Qualitätszirkel
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 AGA Qualitäts- und Risikomanagement (31.07.2019)
RM15	Preoperative, complete presentation of necessary findings AGA Qualitäts- und Risikomanagement (31.07.2019)
RM16	Procedure to avoid procedural and patient mix-ups AGA Qualitäts- und Risikomanagement (31.07.2019)
RM17	Standards for recovery and postoperative care AGA Qualitäts- und Risikomanagement (31.07.2019)
RM18	Discharge management AGA Qualitäts- und Risikomanagement (31.07.2019)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Umsetzung AGA Risk List Meldesystem für kritische Ereignisse (CIRS) etabliert

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 24.01.2019
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

No.

Explanation

IF01

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

As of: 24.01.2019

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

Across all institutions

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)