Deutsches Rotes Kreuz Krankenhaus Lichtenstein Gemeinnützige GmbH

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Dealing with risks in patient care

Quality management

Responsible person

Lysanne Schwanitz

QMB

Hartensteiner Straße 42
09350 Lichtenstein

Phone: 037204-321008-
Mail: ed.shk-krd@ennasyl.ztinawhcs

Steering committee

Qualitätszirkel finden interdisziplinär statt. Die Teilnahme von Verwaltung, Pflegedienstleitung u. ärztl. Vertretern gewährleistet die umfassende Bearbeitung der Projekte. Bei Bedarf werden diese im Rahmen verschiedener Gremien besprochen (z. B. Chefarztberatung, Betriebsleitung, Stationsleitung).

Conference frequency: quartalsweise

Risk management

Responsible person

Risikomanagementbeauftragter, stellvert. Geschäftsführer

Falk Wagner

Hartensteiner Straße 42
09350 Lichtenstein

Phone: 037204-321000-
Mail: ed.shk-krd@klaf.rengaw

Steering committee

Beteiligte Abteilungen / Funktionsbereiche: Geschäftsleitung, Betriebsleitung, QMB und weitere Beauftragte je nach Gattung der zu bearbeitenden Themen

Conference frequency: quartalsweise

Risk management instruments and measures

Instruments and measures

No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Managementhandbuch (10.08.2020)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Managementhandbuch (10.08.2020)
RM05	Pain management Managementhandbuch (10.08.2020)
RM06	Fall prophylaxis Expertenstandard Sturz (24.10.2019)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitus (19.07.2019)
RM09	Regulated handling of occurring malfunctions of devices Managementhandbuch (10.08.2020)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Pathologiebesprechungen Radiologiebesprechung interdisziplinäre Perinatalbesprechung
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 Managementhandbuch (10.08.2020)
RM15	Preoperative, complete presentation of necessary findings Managementhandbuch (10.08.2020)
RM16	Procedure to avoid procedural and patient mix-ups Managementhandbuch (10.08.2020)
RM17	Standards for recovery and postoperative care Managementhandbuch (10.08.2020)
RM18	Discharge management Managementhandbuch (10.08.2020)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: bei Bedarf

Measures

verstärkte Schulungen bei Anwendungssoftware, bauliche Maßnahmen, Einführung des Patientenidentifikationsarmbandes, Leitfaden zu verschiedenen Risiko-Themen, Durchführen einer Risikoinventur

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 22.10.2020
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 quartalsweise

No.

Explanation

IF01

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

As of: 22.10.2020

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 quartalsweise

Across all institutions

Conference committee

Conference frequency: bei Bedarf

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)