Dealing with risks in patient care
Quality management
Claudia-Christine Szulfer-Pollak, MHM
QMB
Bolardusstraße 20
26721 Emden
Phone:
04941
-94-1140
Mail:
ed.k-e-u@kallop-refluzs.enitsirhc-aidualc
Conference frequency:
Risk management
Conference frequency:
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available -siehe das DMS im Nexus Curator -Dok.-Nr. 20523 Verfahrensanweisung Beschwerdemanagement -Dok.-Nr. 22338 Vorlage M & M Konferenz (26.09.2025) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management -Dok.-Nr. 25286 Fortbildungskatalog 2025(?) S.14 (26.09.2025) |
| RM05 |
Pain management -Dok.-Nr. 22689 Expertenstandard Schmerzmanagement in der Pflege -Dok.-Nr. 28568 "One Minute Wonder" Akuter vs Chronischer Schmerz (26.09.2025) |
| RM06 |
Fall prophylaxis -Dok.-Nr. 22690 Expertenstandard Sturzprophylaxe in der Pflege -Dok.-Nr. 24620 Verfahrensanweisung Sturzprophylaxe -Dok.-Nr. 26517 Flyer Sturzprophylaxe (26.09.2025) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) -Dok.-Nr. 22683 Expertenstandard Dekubitusprophylaxe in der Pflege (01.12.2023) |
| RM08 |
Regulated handling of custodial measures - (15.10.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices -Meldung auftretender Fehlfunktionen von Geräten über das IT-Tool HSD Nova (Emden Medizintechnik) (26.09.2025) |
| 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 OP-Planung (13.11.2016) |
| RM15 |
Preoperative, complete presentation of necessary findings OP-Fall-Besprechung (12.11.2016) |
| RM16 |
Procedure to avoid procedural and patient mix-ups -Dok.-Nr. 29148 Verfahrensanweisung sichere Patientenidentifikation -Dok.-Nr. Checkliste sichere Patientenidentifikation (26.09.2025) |
| RM17 |
Standards for recovery and postoperative care Standard operating procedures (30.05.2017) |
| RM18 |
Discharge management -Dok.-Nr. 22684 Expertenstandard Entlassungsmanagement in der Pflege (26.09.2025) |
Fault reporting systems
Conference committee
Conference frequency: halbjährlich
Measures
Patientenidentifikationsarmbänder Team-time-out Vier-Augen-Prinzip bei Medikamenten Sicherheit im Umgang mit Medizinprodukten POCT-Beauftragte Anwendung von Assessmentinstrumenten Hygienemanagement strukturierte Fallbesprechungen
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 04.03.2024 |
| IF02 |
Internal evaluation of the received reports taken quartalsweise |
| 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:
| No. | Explanation |
|---|---|
| EF01 |
CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association) |
| EF13 |
DokuPIK (Documentation of Pharmaceutical Interventions in Hospitals at the Federal Association of German Hospital Pharmacists (ADKA) |