Dealing with risks in patient care
Quality management
Frau Dr. Antje Hoffmann
Ärztliche Direktorin
Fuhrberger Straße 8
30938 Burgwedel
Phone:
05139
-801-3317
Mail:
ed.hrk@nnamffoh.ejtna
Regelhaft: - Direktorium - Chefärzte - Pflegedienstleitung - Bereichsleitungen - Fachabteilungen - QMB's der Standorte - QM-Multiplikatoren - Zertifizierte Zentren
Conference frequency: quartalsweise
Risk management
Antje Hoffmann
Ärztliche Direktorin
30929 Burgwedel
Phone:
05139
-801-3317
Fax: 05139-801-5361
Mail:
ed.hrk@nnamffoh.ejtna
Regelhaft: - Direktorium - Chefärzte - Pflegedienstleitung - Bereichsleitungen - Fachabteilungen - QMB's der Standorte - QM-Multiplikatoren - Zertifizierte Zentren
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available DLS (Dokumentenlenkungssytem), Intrafox Risikomanagement, klinisches Risikomanagement (26.07.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management DLS (Dokumentenlenkungssytem), Intrafox Risikomanagement, klinisches Risikomanagement (26.07.2022) |
| RM05 |
Pain management DLS (Dokumentenlenkungssytem), Intrafox Risikomanagement, klinisches Risikomanagement (26.07.2022) |
| RM06 |
Fall prophylaxis SAP und DLS (07.05.2024) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Intranet und DLS (25.07.2024) |
| RM08 |
Regulated handling of custodial measures Dokumentation im Intranet (24.05.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Richtlinie Medizintechnik im DLS (46446) (19.06.2024) |
| 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 DLS (Dokumentenlenkungssytem), Intrafox Risikomanagement, klinisches Risikomanagement (26.07.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings DLS (Dokumentenlenkungssytem), Intrafox Risikomanagement, klinisches Risikomanagement (26.07.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups DLS (Dokumentenlenkungssytem), Intrafox Risikomanagement, klinisches Risikomanagement (26.07.2022) |
| RM17 |
Standards for recovery and postoperative care DLS (Dokumentenlenkungssytem), Intrafox Risikomanagement, klinisches Risikomanagement (26.07.2022) |
| RM18 |
Discharge management Prozessbeschreibung Entlassungsmanagement zur Zeit im Intranet (25.07.2024) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Konzernweites, webbasiertes CIRS
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 15.11.2022 |
| 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: bei Bedarf
| No. | Explanation |
|---|---|
|
Other |