Dealing with risks in patient care

Quality management

Judith Emich

Qualitätsbeauftragte

Albert-Schweitzer-Straße 40 - 44
14974 Ludwigsfelde

Phone: 03378 -828-2148
Mail: ed.suahnessinokaid@hcime.htiduj

Kaufmännische Direktion, Pflegedirektion, Ärztliche Direktion, Geschäftsführung, Zentrales Qualitätsmanagement, lokales Qualitätsmanagement

Conference frequency: monatlich

Risk management

Burkhard Schult

Ärztlicher Direktor, Prozessverantwortlicher für das Klinische Risikomanagement

Phone: 03378 -828-2406
Fax: 03378-828-2404
Mail: ed.suahnessinokaid@tluhcs.drahkrub

Vorstand, Geschäftsführung, Klinikleitung, Risikokoordinator

Conference frequency: jährlich

Risk management instruments and measures

No. Explanation
RM01

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

Risikomanagementhandbuch und Risikoatlas (11.11.2022)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Diverse fachspezifische Dokumente zum Notfallmanagement, u.a. Interdisziplinäre Schockraumleitlinie (04.07.2021)

RM05

Pain management

Experten Standard (01.10.2022)

RM06

Fall prophylaxis

Sturzprophylaxe in der PflegeExpertenstandard (10.10.2022)

RM07

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

Handbuch Dekubitusmanagement (12.10.2022)

RM09

Regulated handling of occurring malfunctions of devices

Störmeldung Fa. Vamed (15.10.2022)

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

OP-Patientensicherheit (18.09.2020)

RM15

Preoperative, complete presentation of necessary findings

Risikomanagementhandbuch und Risikoatlas (11.11.2022)

RM16

Procedure to avoid procedural and patient mix-ups

Risikomanagementhandbuch und Risikoatlas (11.11.2022)

RM17

Standards for recovery and postoperative care

Kriterien für die Entlassung aus dem Aufwachraum (28.11.2018)

RM18

Discharge management

Entlassmanagement und mitgeltende Dokumente (27.11.2021)

Fault reporting systems

Conference committee

Conference frequency: bei Bedarf

Measures

Schulungsmaßnahmen

No. Explanation
IF01

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

As of: 26.01.2023

IF02

Internal evaluation of the received reports

taken bei Bedarf

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
EF03

KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors)