Dealing with risks in patient care

Quality management

Franziska Lips

Qualitäts- und Risikomanagement

Paul-Gerhardt-Straße 42-45
06886 Lutherstadt Wittenberg

Phone: 03491 -50-2888
Mail: ed.dsj@tfitsgp.tnemeganamsteatilauq

Direktorium mit Vertretung aller Bereiche des Krankenhauses

Conference frequency: andere Frequenz

Risk management

Franziska Lips

Qualitäts- und Risikomanagement

Paul-Gerhardt-Straße 42-45
06886 Lutherstadt Wittenberg

Phone: 03491 -50-2888
Mail: ed.dsj@tfitsgp.tnemeganamsteatilauq

Direktorium mit Vertretung aller Bereiche des Krankenhauses

Conference frequency: andere Frequenz

Risk management instruments and measures

No. Explanation
RM01

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

VA "Strategie Klinisches Risikomanagement" (06.08.2020)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

VA "Medizinisches Notfallmanagement" (23.03.2021)

RM05

Pain management

VA "Strategie Klinisches Risikomanagement" (06.08.2020)

RM06

Fall prophylaxis

VA "Sturzprophylaxe" (17.02.2022)

RM07

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

VA "Dekubitusprophylaxe" (10.08.2021)

RM08

Regulated handling of custodial measures

VA "Umgang mit freiheitsentziehenden Maßnahmen" (18.12.2019)

RM09

Regulated handling of occurring malfunctions of devices

Dienstanweisung "Umgang mit Medizinprodukten" (21.12.2021)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Pathologiebesprechungen
  • Palliativbesprechungen
  • Andere Instrumente und Maßnahmen
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-Checkliste (24.07.2020)

RM15

Preoperative, complete presentation of necessary findings

OP-Checkliste (24.07.2020)

RM16

Procedure to avoid procedural and patient mix-ups

OP-Checkliste (24.07.2020)

RM17

Standards for recovery and postoperative care

VA "Postoperatives Komplikationsmanagement" (13.09.2016)

RM18

Discharge management

VA "Entlassungsmanagement" (02.10.2018)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Kontinuierliche Verbesserung sicherheitsrelevanter Prozesse (Beispiel aus 2021: Standardisierung der ITS-Verlegungsberichte für jede Fachabteilung)

No. Explanation
IF01

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

As of: 28.01.2021

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