Dealing with risks in patient care
Quality management
Katrin Domeyer
Ltg. Qualitäts- / Hygienemanagement (QMB)
Bischofsholer Damm 160
30173 Hannover
Phone:
0511
-3667-570
Mail:
ed.kinilkneihpos@reyemod.nirtak
QM-Team: QMB, Verwaltungsleitung, Leitung Pflegemanagement, Hauswirtschaftsleitung, OP Leitung
Conference frequency: quartalsweise
Risk management
Katrin Domeyer
Ltg. Qualitäts- / Hygienemanagement (QMB)
Bischofsholer Damm 160
30173 Hannover
Phone:
0511
-3667-570
Fax: 0511-3667-579
Mail:
ed.kinilkneihpos@reyemod.nirtak
QMB, Verwaltungsleitung, Leitung Pflegemanagemnt und CIRS-Mentoren aus jeder Abteilung
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM Handbuch (01.12.2022) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management QM Handbuch (01.12.2022) |
| RM05 |
Pain management QM Handbuch (01.12.2022) |
| RM06 |
Fall prophylaxis QM-Handbuch (01.12.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) QM-Handbuch (01.12.2022) |
| RM08 |
Regulated handling of custodial measures QM-Handbuch (01.12.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices QM-Handbuch (01.12.2022) |
| 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 QM Handbuch (01.12.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings QM Handbuch (01.12.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups QM-Handbuch (01.12.2022) |
| RM17 |
Standards for recovery and postoperative care QM Handbuch (01.12.2022) |
| RM18 |
Discharge management QM Handbuch (01.12.2022) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Stellen der Medikamente unter Vier-Augenprinzip, Einsatz OP-Sicherheits-Checkliste, sichere Patientenidentifikation, Sturzprävention mit Sturz-Assesment bei Risikopatienten, Systematisches Dekubitus- und Wundmanagement, Hygiene: MRSA/MRGN -Screening von Risikopatienten, Teilnahme an Aktion Saubere Hände, Teilnahme am NRZ-KISS
| No. | Explanation |
|---|---|
| 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 bei Bedarf |
Conference committee
Conference frequency: monatlich
| No. | Explanation |
|---|---|
|
Other |
|
| EF03 |
KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors) |