Dealing with risks in patient care
Quality management
Monika Döbl
Assistenz der GF, QM & Marketing,
Schützenstaße 55
23843 Bad Oldesloe
Phone:
04531
-68-2443
Mail:
moc.soipelksa@lbeod.m
Geschäftsführung, Ärztlicher Direktor, Chefärzte, Pflegedienstleitung, Betriebsrat und Qualitätsmanagement-Beauftragte
Conference frequency: monatlich
Risk management
Monika Döbl
Assistenz der GF, QM & Marketing,
Schützenstr.
23843 Bad Oldesloe
Phone:
04531
-68-2443
Mail:
moc.soipelksa@lbeod.m
Geschäftsführung, Ärztlicher Direktor, Chefärzte, Pflegedienstleitung, Betriebsrat und Qualitätsmanagement-Beauftragte
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Zentrale VA CIRS (14.03.2024) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management VA-Medizinisches Notfallmanagment (13.03.2024) |
| RM06 |
Fall prophylaxis Sturzprophylaxe (03.03.2025) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusprophylaxe (07.02.2025) |
| RM08 |
Regulated handling of custodial measures Umgang mit freiheitsentziehenden Maßnahmen (10.10.2025) |
| RM09 |
Regulated handling of occurring malfunctions of devices Organisationshandbuch Medizintechnik (18.04.2024) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM13 |
Application of standardised surgical check lists |
| RM16 |
Procedure to avoid procedural and patient mix-ups Vermeidung einer Eingriffsverwechslung (15.07.2024) |
| RM17 |
Standards for recovery and postoperative care Postoperative Schmerztherapie (19.02.2025) |
| RM18 |
Discharge management Entlassmanagement Akuthaus (11.01.2024) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
- kontinuierliche Fortbildungen (Ärzte/Pflege) zum Thema Hygiene (speziell zu MRSA / ISO Patienten) - Information der Mitarbeitenden über klinikeigene CIRS-Meldungen sowie über konzernweiten CIRS-Fall des Monats
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 12.04.2024 |
| IF02 |
Internal evaluation of the received reports taken monatlich |
| 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 |
|---|---|
|
Other |
|
| EF14 |
CIRS Health Care |