Neckar-Odenwald-Kliniken gGmbH

No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available [1_K_13_13006] Risikomanagement Version 5; [1_K_13_13005] Qualitätsmanagement Version 6 (26.10.2021)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management [7_K_13_13003] Innerklinisches medizinisches Notfallmanagement Version 5 (17.06.2021)
RM05	Pain management [7_VA_06_6004] Akutschmerz eines Patienten Version 3; [7_S_08_8050] Schmerzmanagement Version 3 (15.04.2019)
RM06	Fall prophylaxis [7_S_08_8032] Sturzprophylaxe Version 2 (25.08.2021)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) [7_S_08_8016] Dekubitusprophylaxe Version 6 (13.10.2020)
RM08	Regulated handling of custodial measures [7_PRO_06_6001] Freiheitsentziehende Maßnahmen Version 3 (06.12.2019)
RM09	Regulated handling of occurring malfunctions of devices [1_VA_13_13001] Umgang mit Medizinprodukten Version 9 (01.06.2021)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Palliativbesprechungen Qualitätszirkel Andere
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 [7_VA_29_29001] Ablaufoptimierung OP OP-Statut Version 6; [7_VA_25_25001] Transfusionshandbuch Version 3 mit Anlage 4 Anforderung von Erythrozytenkonzentraten für elektive Eingriffe (22.09.2021)
RM15	Preoperative, complete presentation of necessary findings [7_VA_13_13008] Vermeiden von Eingriffsverwechslungen mit Checklisten Version 4 mit Checklisten (14.08.2018)
RM16	Procedure to avoid procedural and patient mix-ups [7_VA_13_13008] Vermeiden von Eingriffsverwechslungen mit Checklisten Version 4 mit Checklisten (14.08.2018)
RM17	Standards for recovery and postoperative care [7_VA_06_6009] Ärztliche Zuständigkeiten Version 2; [7_PRO_06_6011] Überwachen eines Patienten im Aufwachraum (30.09.2020)
RM18	Discharge management [7_VA_06_6012] Koordiniertes Entlassmanagement Version 3, [3_S_06_6045] Entlassmanagement GYN_GEB (26.04.2021)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: halbjährlich

Measures

1. Aufgrund der Corona-Pandemie werden Mitarbeiter aus verschiedenen Berufsgruppen in unterschiedlichen Bereichen flexibel eingesetzt, um die neuen Herausforderungen gut meistern zu können. 2. Umsetzung der Besucherregelungen sowie weiteren Vorgaben aufgrund der Pandemie nach den aktuellen Empfehlungen.

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 22.05.2020
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 halbjährlich

No.

Explanation

IF01

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

As of: 22.05.2020

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 halbjährlich

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)