Dealing with risks in patient care
Quality management
Dipl. Pflegewirtin Karin Weiß
Stellv. Pflegedienstleitung/Qualitätsmanagerin
Am Krankenhaus 4
27711 Osterholz-Scharmbeck
Phone:
04791
-803-439
Mail:
ed.zhohkk@ssiew.k
Krankenhausleitung, Pflegedienstleitung, Chefärzte der Inneren Medizin, Chefarzt der Chirurgie, Qualitätsmanagement
Conference frequency: quartalsweise
Risk management
Frauke Fröhlich
Stellv. Krankenhausleitung
Am Krankenhaus 4
27711 Osterholz-Scharmbeck
Phone:
04791
-803-221
Fax: 04791-803-339
Mail:
ed.zhohkk@hcilheorf.f
Frauke Fröhlich
Stellv. Krankenhausleitung
Am Krankenhaus 4
27711 Osterholz-Scharmbeck
Phone:
04791
-803-221
Fax: 04791-803-339
Mail:
ed.zhohkk@hcilheorf.f
Krankenhausleitung, Pflegedienstleitung, Chefärzte der Inneren Medizin, Chefarzt der Chirurgie, Qualitätsmanagement
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Leitfaden Mortalitäts- und Morbiditätskonferenzen (21.09.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Notfallplan_V.6_2023 (23.08.2023) |
| RM05 |
Pain management Schmerz-Algorithmus (15.06.2023) |
| RM06 |
Fall prophylaxis Sturzrisikoerfassungsbogen (01.09.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard zur Dekubitusprophylaxe (23.08.2023) |
| RM08 |
Regulated handling of custodial measures Fixierung von Patienten (26.09.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Dokumente zur Umsetzung des MPG (17.07.2023) |
| 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 Checkliste OP-Sicherheit (24.11.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings Checkliste OP-Sicherheit (24.11.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Checkliste OP-Sicherheit (24.11.2022) |
| RM17 |
Standards for recovery and postoperative care Postoperativer Behandlungsbogen (04.11.2022) |
| RM18 |
Discharge management Entlassmanagement (22.08.2023) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Die Vorschläge werden mit den beteiligten Personen und Berufsgruppen sorgfältig bewertet und entsprechend umgesetzt.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 23.08.2023 |
| 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 jährlich |
Conference committee
Conference frequency: monatlich
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors) |