Dealing with risks in patient care

Quality management

Miriam Haubold

Qualitätsmanagementbeauftragte

Dobenaustraße 130
08523 Plauen

Phone: 03741 -172-158
Mail: ed.nocaide@dlobuah.mairim

Ärztliche Direktion, Pflegedirektion, Betriebsdirektion, QM

Conference frequency: quartalsweise

Risk management

Basel Al Kadah

Chefarzt

Dobenaustraße 130
08523 Plauen

Phone: 03741 -172-201
Fax: 03741-172-218
Mail: ed.nocaide@hadakla.lesab

Ärztliche Direktion, Pflegedirektion, Betriebsdirektion, QM

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

AMD Risikomanagementhandbuch (01.01.2020)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Reanimationsrichtlinien (16.03.2021)

RM05

Pain management

VA Schmerzmanagement (18.08.2021)

RM06

Fall prophylaxis

Verfahrensanweisung Sturzmanagement (06.05.2019)

RM07

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

KBP VA Dekubitus (01.02.2022)

RM08

Regulated handling of custodial measures

AMD Risikomanagementhandbuch (01.01.2020)

RM09

Regulated handling of occurring malfunctions of devices

AGA AMTech Handbuch Medizintechnik (27.07.2021)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
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

OP-Statut, Rahmenplanung (16.04.2021)

RM15

Preoperative, complete presentation of necessary findings

AMD Risikomanagementhandbuch (01.01.2020)

RM16

Procedure to avoid procedural and patient mix-ups

AGA Vermeidung von Eingriffs- und Seitenverwechslungen (15.07.2022)

RM17

Standards for recovery and postoperative care

Standards für Aufwachraum, Entlassungskriterien Aufwachraum (01.03.2021)

RM18

Discharge management

KBP VA Entlass Management (04.11.2020)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Einsatz von Patient:innenidentifikationsarmbändern, um Verwechslungen zu vermeiden; Frühwarnsystem Critical Incident Reporting System (CIRS) zur Schadensvermeidung; Einsatz von Sicherheitschecklisten im OP; Umsetzung des AGA Hygieneplans; Screening-Vorgaben für Patient:innen mit multiresistenten Erregern; Teilnahme an der "Aktion Saubere Hände" mit Zertifikat Bronze

No. Explanation
IF01

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

As of: 23.05.2022

IF02

Internal evaluation of the received reports

taken monatlich

Conference committee

Conference frequency: bei Bedarf

No. Explanation

Other

Other