Dealing with risks in patient care

Quality management

Anja Preiss

QMB

Eppenreuther Str. 9
95032 Hof

Phone: 09281 -98-3322
Mail: ed.anas@ssierp.ajna

Geschäftsführung, Pflegedirektion, Kaufmännische Leitung, QMB

Conference frequency: monatlich

Risk management

Anja Preiss

QMB

Eppenreuther Str. 9
95032 Hof

Phone: 09281 -98-3322
Fax: 09281-98-2627
Mail: ed.anas@ssierp.ajna

Geschäftsführung, Pflegedirektion, Kaufmännische Leitung, QMB

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

Comprehensive quality and/or risk management documentation (QM/RM documentation) is available

QM System Sana Klinikum Hof, Sana Management Handbuch (14.11.2022)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Verfahrensanweisung Medizinisches Notfallmanagement, Sana Management Handbuch (26.04.2022)

RM05

Pain management

Arbeitsanweisungen Allgemeine Schmerztherapie (19.08.2020)

RM06

Fall prophylaxis

Verfahrensanweisung Sturzprophylaxe und Sturzerfassung (01.07.2020)

RM07

Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”)

Verfahrensanweisung Dekubitusprophylaxe, Sana Management Handbuch (23.08.2022)

RM08

Regulated handling of custodial measures

Verfahrensanweisung Freiheitsentziehende Maßnahmen - FEM, Sana Management Handbuch (23.08.2022)

RM09

Regulated handling of occurring malfunctions of devices

QM System Sana Klinikum Hof; Samba Handbuch, Sana Management Handbuch (14.11.2022)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Palliativbesprechungen
  • Simulationstrainings
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

Verfahrensanweisung und Formular Einsatz OP-Sicherheits-Checkliste, Sana Management Handbuch (17.11.2022)

RM15

Preoperative, complete presentation of necessary findings

Verfahrensanweisung und Formular Einsatz OP-Sicherheits-Checkliste, Sana Management Handbuch (17.11.2022)

RM16

Procedure to avoid procedural and patient mix-ups

Arbeitsanweisung Patientenidentifikationsband und Arbeitsanweisung Patientenidentifikationsband Kinderklinik Kreißsaal, Sana Management Handbuch (09.05.2022)

RM17

Standards for recovery and postoperative care

Verfahrensanweisung Aufnahme und Versorgung postoperativer Patienten, Sana Management Handbuch (28.10.2019)

RM18

Discharge management

Verfahrensanweisung Entlassmanagement (23.08.2021)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

OP-Sicherheits-Checkliste WHO, Patientenidentifikationsband, Morbiditäts- und Mortalitätskonferenz, Dekubitusprävention, Sturzprävention, Simulationstraining

No. Explanation
IF01

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

As of: 01.11.2022

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 quartalsweise

Conference committee

Conference frequency: monatlich

No. Explanation

Other