Dealing with risks in patient care
Quality management
Liliya Kudayeva
Qualitäts- und Risikomanagement Beauftragte
Neumeyerstr. 46-48
90411 Nürnberg
Phone:
0911
-58068-0
Mail:
moc.knilk013@ofni
QM
Conference frequency: quartalsweise
Risk management
Liliya Kudayeva
Qualitäts- und Risikomanagement Beauftragte
Neumeyerstraße 46-48
90411 Nürnberg
Phone:
0911
-58068-0
Fax: 0911-58068-1150
Mail:
moc.knilk013@ofni
QM
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM Auditierung ISO 9001:2015 durch TÜV (27.06.2023) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management SOP Notfallmanagement (07.03.2025) |
| RM05 |
Pain management PB perioperative Schmerztherapie (07.03.2025) |
| RM06 |
Fall prophylaxis Qualitäts- und Risikomanagementhandbuch (27.06.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Qualitäts- und Risikomanagementhandbuch (27.06.2023) |
| RM08 |
Regulated handling of custodial measures SOP freiheitsentziehende Maßnahmen (10.01.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Meldung von Defekten Fehlfunktionen an Geräten (17.06.2025) |
| 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 Risikomanagementhandbuch (08.06.2025) |
| RM15 |
Preoperative, complete presentation of necessary findings Teil der QM/RM-Dokumentation (27.06.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups SOP Seitenmarkierung (16.08.2024) |
| RM17 |
Standards for recovery and postoperative care Teil der QM/RM-Dokumentation (27.06.2023) |
| RM18 |
Discharge management Teil der QM/RM-Dokumentation (27.06.2023) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Markierung der Patienten vor OP durch den behandelnden Arzt, Patientenarmband, mehrsprachige Information zur Nüchternheit vor OP
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 21.06.2022 |
| IF02 |
Internal evaluation of the received reports taken bei Bedarf |
| 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 |
|---|---|
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |