Dealing with risks in patient care
Quality management
Sylvie Schraut
Leitung Qualitäts- und Risikomanagement, Patientensicherheitsbeauftragte
Bismarckstraße 23
87700 Memmingen
Phone:
08331
-70-1587
Mail:
ed.negnimmem-mukinilk@eivlys.tuarhcs
Qualitätszirkel, interdisziplinär; Risikoausschuss, interprofessionell
Conference frequency: quartalsweise
Risk management
Sylvie Schraut
Leitung Qualitäts- und Risikomanagement, Patientensicherheitsbeauftragte
Bismarckstraße 23
87700 Memmingen
Phone:
08331
-70-1587
Fax: 08331-70-2832236
Mail:
ed.negnimmem-mukinilk@eivlys.tuarhcs
Klinische Risikomanager in Unfallchirurgie, Medizinischen Klinik, Kreißsaal, Pädiatrie, Radiologie, Qualitätsmanagement
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Online - System DIN EN/ISO 9001:2015 / Risiko- und Maßnahmentool tagesaktuell; Vorgabedokumente: (23.03.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Online - System DIN EN/ISO 9001:2015 / D07589 (22.06.2023) |
| RM05 |
Pain management Online - System DIN EN/ISO 9001:2015 / D02642 (12.10.2023) |
| RM06 |
Fall prophylaxis Online - System DIN EN/ISO 9001:2015 / D04474 (01.03.2024) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Online - System DIN EN/ISO 9001:2015 / D00753 (06.04.2023) |
| RM08 |
Regulated handling of custodial measures Online - System DIN EN/ISO 9001:2015 / Do3oo7 (08.11.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Online - System DIN EN/ISO 9001:2015 / D01826 (27.03.2023) |
| 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 Online - System DIN EN/ISO 9001:2015 / D031159 (26.06.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Online - System DIN EN/ISO 9001:2015 / D02150 (12.10.2023) |
| RM17 |
Standards for recovery and postoperative care Online - System DIN EN/ISO 9001:2015 / D03203 (04.04.2024) |
| RM18 |
Discharge management Online - System DIN EN/ISO 9001:2015 / D08819 (01.04.2022) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
"CIRS - Fall des Monats"wird klinikweit kommuniziert, Inhouse-Schulungen Risikomanagement,Interne Audits, Ausbildung und Zertifizierung klinischer Riskomanager,Empfehlung von Verbesserungsmaßnahmen an die Krankenhausleitung, Implemetierung Patientensicherheit ins QM-System,Einführung regelmäßiger Risikoanalysen, Teilnahme an CIRSmedical, Einführung strukturierter Risikotools
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 12.10.2023 |
| 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 bei Bedarf |
Conference committee
Conference frequency: quartalsweise
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |