Dealing with risks in patient care
Quality management
M.A. Janna Worms
Leitung Medizinisches Qualitäts- und Risikomanagement
Flemmingstraße 2
09116 Chemnitz
Phone:
0371
-333-32492
Mail:
ed.cks@smrow.annaj
Ärztlicher Dienst, Pflegedienst, Krankenhausapotheke, Krankenhaushygiene, Zentrales Qualitäts- und Risikomanagement, QM-Beauftragte der Kliniken und Abteilungen, Geschäftsführung
Conference frequency: quartalsweise
Risk management
Janna Worms
Leitung Medizinisches Qualitäts- und Risikomanagement
Phone:
0371
-333-32492
Fax: 0371-333-32475
Mail:
ed.cks@smrow.annaj
Ärztlicher Dienst, Pflegedienst, Krankenhausapotheke, Krankenhaushygiene, Zentrales Qualitäts- und Risikomanagement, QM-Beauftragte der Kliniken und Abteilungen, Geschäftsführung
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikohandbuch KC-RM-VA-00005 (30.07.2025) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Innerklinisches Notfallmanagement (KC-ZITS-VA-00001) (18.06.2021) |
| RM05 |
Pain management Schmerzmanagement in der Pflege (KC-VD-VA-00042) inkl. verschiedenster Skalen (14.01.2022) |
| RM06 |
Fall prophylaxis Sturzprophylaxe in der Pflege (KC-PATB-VA-00012) (09.10.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusprohylaxe DEKU- PR(KC-PATB-PS-00001) (07.02.2024) |
| RM08 |
Regulated handling of custodial measures Fixierung (KC-PATB-VA-00010) (17.06.2025) |
| RM09 |
Regulated handling of occurring malfunctions of devices Betreiben und Benutzen von Produkten (KC-MPB-VA-00001) (13.03.2025) |
| 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 Anästhesieprotokoll --> Erfassung erfolgt in Narkodata (07.05.2025) |
| RM15 |
Preoperative, complete presentation of necessary findings Prüfliste Patientensicherheit inkl. Team-time-Out (14.10.2024) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Patientenidentifizierung; Namensbänder; OP-Checkliste inkl. Time-Time-out (KC-PV-VA-00010) (24.04.2023) |
| RM17 |
Standards for recovery and postoperative care u.a. Postoperative Versorgung im BZ (BZ-PATB-VA-00017), Postoperative Behandlungsverfahren in der Unfallchirurgie (KCHI-PATB-FB-00025), Überwachungsprotokoll Notfall- und postoperative Patienten (03.12.2024) |
| RM18 |
Discharge management Risikohandbuch KC-RM-VA-00005 (30.07.2025) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Neue Regelungen beim Umgang mit suizidalen Patient*innen
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 11.06.2025 |
| 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: bei Bedarf
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |