Dealing with risks in patient care
Quality management
Frau Anne Ehlert
QMB
Wöhrendamm 80
22927 Großhansdorf
Phone:
04102
-601-1800
Mail:
ed.cinilcnegnul@trelhe.a
Medizinische Geschäftsführung, Kaufmännische Geschäftsführung, Pflegedienstleitung, Chefärzte, Betriebsratsvorsitzende/r, Qualitätsmanagement
Conference frequency: monatlich
Risk management
Anne Ehlert
QMB
Wöhrendamm 80
22927 Großhansdorf
Phone:
04102
-601-1800
Fax: 04102-601-7001
Mail:
ed.cinilcnegnul@trelhe.a
Kaufmännische Geschäftsführung, Oberarzt Thoraxchirurgie, Stationsleitung Pneumologie, Stationsleitung Onkologie und Thoraxchirurgie, Referentin für Digitalisierungsprozesse/ Ambulanzmanagerin, Qualitätsmanagement, Leitung Finanz-und Rechnungswesen, ISB
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QMH-Risikomanagement (25.06.2019) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Medizinische Notfallversorgung-"Herzalarm" (18.06.2021) |
| RM05 |
Pain management PB Perioperative Schmerztherapie (10.10.2024) |
| RM06 |
Fall prophylaxis Sturzprophylaxe (25.08.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusprophylaxe (01.07.2024) |
| RM08 |
Regulated handling of custodial measures Freiheitsbeschränkende/ -entziehende Maßnahmen (07.06.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices Vorkommnis melden (13.07.2020) |
| 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 Patientensicherheit im OP (08.08.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings Patientensicherheit im OP (08.08.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Patientensicherheit im OP (08.08.2023) |
| RM17 |
Standards for recovery and postoperative care Postoperative Patientenbetreuung (14.08.2018) |
| RM18 |
Discharge management Dienstanweisung Entlass-und Überleitungsmanagement (13.09.2024) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Etablierung eines Philips-Servers, Information des Pflegepersonals über die im Medico-Handbuch beschriebene Regelung, wie Zugänge in der Pflegedokumentation erfasst werden
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 13.09.2024 |
| 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 |
Conference committee
Conference frequency: bei Bedarf
| No. | Explanation |
|---|---|
| EF14 |
CIRS Health Care |