Dealing with risks in patient care

Quality management

Tanja Hewelt

Leitung Verwaltung

Alte Holstenstraße 2 und 16
21031 Hamburg

Phone: 040 -72575-290
Mail: ed.frodegreb-kinilk-sixarp@tleweh

Verwaltung / Station / OP

Conference frequency: monatlich

Risk management

Jan-Michael Lenk

Anästhesist / QM-Beauftragter

Phone: 040 -72575-292
Fax: 040-72575-192
Mail: ed.frodegreb-kinilk-sixarp@knel

Verwaltung / Station / OP

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

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

PKB_QMH (15.12.2022)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

PKB_QMH (15.12.2022)

RM05

Pain management

PKB_QMH (15.12.2022)

RM06

Fall prophylaxis

PKB_QMH (15.12.2022)

RM07

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

PKB_QMH (15.12.2022)

RM08

Regulated handling of custodial measures

PKB_QMH (15.12.2022)

RM09

Regulated handling of occurring malfunctions of devices

PKB_QMH (15.12.2022)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
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

PKB_QMH (15.12.2022)

RM15

Preoperative, complete presentation of necessary findings

PKB_QMH (15.12.2022)

RM16

Procedure to avoid procedural and patient mix-ups

PKB_QMH (15.12.2022)

RM17

Standards for recovery and postoperative care

PKB_QMH (15.12.2022)

RM18

Discharge management

PKB_QMH (15.12.2022)

Fault reporting systems

Conference committee

Conference frequency: bei Bedarf

Measures

Einzel- und/oder Teambesprechungen, ggfls. Abänderung/Konkretisierung von Verfahrensanweisungen, Checklisten und Arbeitsanweisungen.

No. Explanation
IF01

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

As of: 14.09.2022

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 halbjährlich

Conference committee

Conference frequency: