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DRK Krankenhaus Biedenkopf

Dealing with risks in patient care

Quality management

Responsible person

A. Cornelia Bönnighausen

Vorstandsvorsitzende & Qualitätsmanagement

Hainstraße 71 - 75
35216 Biedenkopf

Phone: 06461 -77-226
Mail: ed.fpoknedeib-krd@tairaterkes

Steering committee

Pflegedienstleitung, Beauftragte aus den Abteilungen/Stationen, QMB, Haustechnik, Hauswirtschaft, IT, Medizinisches und kaufmännisches Controlling, Verwaltungsleitung

Conference frequency: monatlich

Risk management

Responsible person

A. Cornelia Bönnighausen

Vorstandsvorsitzende & Qualitätsmanagement

35202 Biedenkopf

Phone: 06461 -77-226
Mail: ed.fpoknedeib-krd@tairaterkes

Steering committee

Risikomanager, Vorstand

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 Risikomeldungen und Risikomatrix/- einschätzung (23.08.2019)
RM02	Regular further education and training measures
RM04	Clinical emergency management Notfall- und Reanimationsteam mit internere Notrufnummer (23.08.2019)
RM05	Pain management Visuelle Analogskala, Numerische Analogskala, Checkliste akuter Brustschmerz, tägliche Dokumentation (23.08.2019)
RM06	Fall prophylaxis Sturzrisikoerhebung bei Aufnahme und regelmäßige Reevaluation, Sturzprotokoll, Expertenstandard Wundbehandlung Dekubitus (23.08.2019)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitusprophylaxe in der Pflege, Bradenskala (23.08.2019)
RM08	Regulated handling of custodial measures Verfahrensanweisung, Expertenstandard Freiheitsentziehende Maßnahmen inkl. SOP (23.08.2019)
RM09	Regulated handling of occurring malfunctions of devices Ticketsystem zur Meldung von Fehlfunktionen an die MPG-Abteilung (23.08.2019)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Palliativbesprechungen Interdisziplinäre Fallbesprechungen auf der Intensivstation
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 OP-Vorbereitung (Anästhesie und Operateur) (23.08.2019)
RM16	Procedure to avoid procedural and patient mix-ups Patienten-Identifikations-Armband, Team-Time-Out, Verpflichtende Seitenangabe bei der OP-Anmeldung (23.08.2019)
RM17	Standards for recovery and postoperative care Behandlungsstandards (23.08.2019)
RM18	Discharge management Durchführung des Entlassmanagement bei jedem Patienten (23.08.2019)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: bei Bedarf

Measures

Dokumentation und geregelter Umgang mit dem Fehlermeldesystem

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 01.07.2016
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 halbjährlich

No.

Explanation

IF01

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

As of: 01.07.2016

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 halbjährlich

Across all institutions

Conference committee

Conference frequency: monatlich

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)