Dealing with risks in patient care
Quality management
Dipl.-Kfm. Axel Post
Geschäftsführer
Sieker Landstraße 19
22927 Großhansdorf
Phone:
04102
-600-515
Mail:
ed.negahnam@tsop.lexa
Beteiligte Abteilungen: Ärtzlicher Direktor; OP-Management; Pflegedienstleitung Funktionsbereiche:; Qualitätsmanagement, Chefärzte; Geschäftsführung
Conference frequency: quartalsweise
Risk management
Jörg Braun
Ärztlicher Direktor und Chefarzt Innere Medizin
Phone:
04102
-605-124
Mail:
ed.negahnam@nuarb.greoj.forp
Beteilige Abteilungen: Ärztlicher Direktor; OP-Management; Pflegedienstleitung Funktionsbereiche: Qualitätsmanagement; Chefärzte; Geschäftsführung
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM Manhagen (31.08.2020) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management QM Manhagen (31.08.2020) |
| RM05 |
Pain management QM Manhagen (31.08.2020) |
| RM06 |
Fall prophylaxis QM Manhagen (31.08.2020) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) QM Manhagen (31.08.2020) |
| RM09 |
Regulated handling of occurring malfunctions of devices QM Manhagen (31.08.2020) |
| 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 QM Manhagen (31.08.2020) |
| RM15 |
Preoperative, complete presentation of necessary findings QM Manhagen (31.08.2020) |
| RM16 |
Procedure to avoid procedural and patient mix-ups QM Manhagen (31.08.2020) |
| RM17 |
Standards for recovery and postoperative care QM Manhagen (31.08.2020) |
| RM18 |
Discharge management QM Manhagen (31.08.2020) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
CIRS-System unter Anleitung eines Chef-Sicherheitspiloten; freiwilliges MRSA-Screening aller Mitarbeiter; Teilnahme an der Aktion Saubere Hände; unangemeldete und externe Kontrollen und Begehungen; Hygienevisiten; Hygieneschulungen der Mitarbeiter; IMC-Station mit Kupfertürkliniken und Kupferschaltern; OP-Checklisten der WHO; Team-Time-Out; Patientenarmbänder zur Vermeidung von Eingriffsverwechslungen; Mitwirkung im Exekutivkomitee des EPRD; größter Datenlieferant EPRD
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.02.2016 |
| 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 quartalsweise |
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) |