Dealing with risks in patient care
Quality management
Anke Mönnich
Leitung Qualitätsmanagement
Chemnitzstr. 33
24116 Kiel
Phone:
0431
-1697-4080
Mail:
ed.leik-suahneknark@hcinneom.ekna
Direktorium Klinik- und Institutsleitungen Qualitätsmanagementbeauftragte
Conference frequency: halbjährlich
Risk management
Kai Helbing
Qualitätsmanagement / klinisches Risikomanagement
Phone:
0431
-1697-4086
Mail:
ed.leik-suahneknark@gnibleh.iak
Direktorium
Conference frequency: jährlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available OD Risikomanagement im SKK (14.09.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management HA Notfallversorgung - Geltungsbereich aber nur 2. Med (01.09.2017) |
| RM05 |
Pain management NES Schmerzmanagement akut (27.10.2014) |
| RM06 |
Fall prophylaxis NES Sturzprophylaxe in der Pflege (12.04.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) NES Dekubitusprophylaxe (05.04.2022) |
| RM08 |
Regulated handling of custodial measures OD FeM (09.09.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices HA Reparaturanforderung für Betten (15.09.2021) |
| 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 OD Risikomanagement im SKK (14.09.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings OD Risikomanagement im SKK (14.09.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups HA Patientenidentifikation (12.10.2017) |
| RM17 |
Standards for recovery and postoperative care OD Risikomanagement im SKK (14.09.2022) |
| RM18 |
Discharge management HA Entlassungs- und Versorgungsmanagement (16.01.2018) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
- Aktualisierung und Kommunikation des Risikokataloges zum klinischen Risikomanagement - Berücksichtigung der Risiken in der Patientenversorgung in den internen DIN ISO Audits - Durchführung von Patientensicherheitsaudits (Umsetzung NES und Funktionsbereich OP) mit Hilfe der internen Auditor*innen des Pflegedienstes - regelmäßige Veröffentlichung eines CIRS-Falls mit besonderer Relevanz
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 30.06.2021 |
| IF02 |
Internal evaluation of the received reports taken halbjährlich |
| 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: quartalsweise
| No. | Explanation |
|---|---|
| EF13 |
DokuPIK (Documentation of Pharmaceutical Interventions in Hospitals at the Federal Association of German Hospital Pharmacists (ADKA) |
| EF14 |
CIRS Health Care |