Dealing with risks in patient care
Quality management
Conference frequency:
Risk management
Monika Gaa
Risikomanagementbeauftragte
Scheuerberg Str. 3
69412 Eberbach
Phone:
06202
-84-653392
Mail:
ed.nrg@aag.akinom
alle
Conference frequency: halbjährlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikomanagement-Handbuch (D6263) (28.10.2024) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Reanimations-/Notfallmanagement (D5387) (28.06.2023) |
| RM05 |
Pain management postoperative Schmerztherapie (D3443) (10.02.2022) |
| RM06 |
Fall prophylaxis 1. Informationsflyer Sturzprophylaxe (D3022) 2. Sturz-Assessment erfolgt in der digitalen Pflegedokumentation (epaAC/ LEP) 3. Sturzprophylaxe in der Pflege nach Expertenstandard (D3814) 4. Sturzprotokoll (D3815) (09.08.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) 1. Dekubitus-Assessment erfolgt in der digitalen Pflegedokumentation (epaAC/ LEP) 2. Erhebungsbogen Anti-Dekubitus-Systeme (D9241) (07.02.2023) |
| RM08 |
Regulated handling of custodial measures 1. Anregung und ärztl. Zeugnis für Genehmigung einer freiheitsentziehenden Maßnahme (D9240) 2. Anregung und ärztl. Zeugnis für Einrichtung einer Eilbetreuung nach §1896 BGB (D9238) 3. Antrag auf richterliche Genehmigung einer freiheitsentziehenden Maßnahme (D9470) 4. Fixierungsprotokoll (D3460) (28.12.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Kurzanleitung Serviceportal Fa. Hermed Medizintechnik (D9914) (04.07.2023) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM13 |
Application of standardised surgical check lists |
| RM15 |
Preoperative, complete presentation of necessary findings 1. Standard präoperative Untersuchungen Anästhesie (D2324) 2. SOP Time-Out (D1678) 3. OP-Checkliste (D1677) (29.08.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Konzept Patientenidentifikationsarmband (D7662) (13.10.2024) |
| RM18 |
Discharge management Aufgaben des Entlassmanagements (D7559) (28.12.2023) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
- SOP "Arzneimittelmanagement während Hitzeperiode" - Pflichtfortbildungen in "Basishygiene, Arbeitsschutz und Datenschutz" für alle Mitarbeitenden - Compliance-Begehungen zur Händedesinfektion durch Hygienefachkraft
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 08.10.2024 |
| IF02 |
Internal evaluation of the received reports taken jährlich |
| IF03 |
Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken monatlich |
Conference committee
Conference frequency: jährlich
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |