Dealing with risks in patient care
Quality management
Dr. med. Alexandra Ebert
Qualitätsmanagement
Schmidbauerstraße 44
81737 München
Phone:
089
-8892-2615
Mail:
ed.tiehdnuseg-soileh@3trebE.ardnaxelA
Conference frequency:
Risk management
Hans-Joachim Andreß
Ärztlicher Direktor
Phone:
089
-67802-222
Fax: 089-67802-399
Mail:
ed.tiehdnuseg-soileh@sserdnA.mihcaoJ-snaH
Jürgen Tudyka
Ärztlicher Direktor
Phone:
089
-67802-221
Fax: 089-67802-398
Mail:
ed.tiehdnuseg-soileh@akyduT.negreuJ
Conference frequency:
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM und RM (zentrales Dokumentationsverzeichnis) (29.09.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Verfahrensbeschreibungen im Rahmen der Zertifizierung als lokales Traumazentrum DGU und Alterstraumazentrum (28.02.2022) |
| RM05 |
Pain management Handlungsempfehlung Schmerzmanagement in der Pflege bei akuten und chronischen Schmerzen (01.09.2019) |
| RM06 |
Fall prophylaxis Beschluss der FG Pflege Sturzprophylaxe (01.02.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Beschluss der FG Pflege Dekubitusprophylaxe (01.11.2021) |
| RM08 |
Regulated handling of custodial measures VA Freiheitsentziehende Maßnahmen (26.08.2014) |
| RM09 |
Regulated handling of occurring malfunctions of devices Verfahrensstandard Umgang mit Produktproblemen (ZD Einkauf) (29.05.2015) |
| 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 Konzernregelung OP-Sicherheit (27.01.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings Konzernregelung OP-Sicherheit (27.01.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Konzernregelung OP-Sicherheit (27.01.2022) |
| RM17 |
Standards for recovery and postoperative care NEWS vor Verlegung/ Wissensziel 2019 (02.03.2017) |
| RM18 |
Discharge management VA ärztliches Entlaßmanagement (25.02.2019) |
Fault reporting systems
Conference committee
Conference frequency: halbjährlich
Measures
erfolgreiche Steigerung der Meldefrequenz, Maßnahmen zur Verbesserung der hausinternen Kommunikation per E-Mail und Hausmitteilung, Verbesserungen des Bettenumlaufs und der Bettenbeschaffung
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 30.11.2016 |
| IF02 |
Internal evaluation of the received reports taken halbjährlich |
| 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: halbjährlich
| No. | Explanation |
|---|---|
| EF02 |
CIRS Berlin (Medical Association Berlin, German Medical Association, National Association of Statutory Health Insurance Doctors) |
| EF03 |
KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors) |