Schwarzwald-Baar Klinikum Villingen-Schwenningen GmbH
Dealing with risks in patient care
Quality management
Klaus Kugel
Abteilungsleitung
Sonnhaldenstraße 2
78166 Donaueschingen
Phone: 07721-93-8350
Mail: ed.sv-kbs@leguk.sualk
Klinikdirektorium (Geschäftsführer, Medizinischer Direktor, Ärztlicher Direktor, Pflegedirektor), Abteilungsleitung Qualitätsmanagement
Conference frequency: monatlich
Risk management
Risikomanagerin
Anika Bauer
78011 Villingen-Schwenningen
Phone: 07721-93-8410
Fax: 07721-93-98410
Mail: ed.sv-kbs@reuab.akina
Klinikdirektorium (Geschäftsführer, Medizinischer Direktor, Ärztlicher Direktor, Pflegedirektor), Abteilungsleitung Risikomanagement
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Verfahrens- und Arbeitsanweisung, SOP (15.12.2020) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Verfahrens- und Arbeitsanweisung, SOP (15.12.2020) |
| RM05 |
Pain management Verfahrens- und Arbeitsanweisung, SOP (15.12.2020) |
| RM06 |
Fall prophylaxis Verfahrens- und Arbeitsanweisung, SOP (15.12.2020) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Verfahrens- und Arbeitsanweisung, SOP (15.12.2020) |
| RM08 |
Regulated handling of custodial measures Verfahrens- und Arbeitsanweisung, SOP (15.12.2020) |
| RM09 |
Regulated handling of occurring malfunctions of devices Verfahrens- und Arbeitsanweisung, SOP (15.12.2020) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| 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 Verfahrens- und Arbeitsanweisung, SOP (15.12.2020) |
| RM15 |
Preoperative, complete presentation of necessary findings Verfahrens- und Arbeitsanweisung, SOP (15.12.2019) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Verfahrens- und Arbeitsanweisung, SOP (15.12.2020) |
| RM17 |
Standards for recovery and postoperative care Verfahrens- und Arbeitsanweisung, SOP (15.12.2020) |
| RM18 |
Discharge management Verfahrens- und Arbeitsanweisung, SOP (15.12.2020) |
Fault reporting systems
Conference committee
Conference frequency: wöchentlich
Measures
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 02.01.2020 |
| IF02 |
Internal evaluation of the received reports taken quartalsweise |
| 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: quartalsweise
| No. | Explanation |
|---|---|
| EF14 |
CIRS Health Care |