St Josefskrankenhaus

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Dealing with risks in patient care

Quality management

Responsible person

Heike Richthammer

Leiterin Qualitätsmanagement

Sautierstr. 1
79104 Freiburg

Phone: 0761-2711-2264
Mail: ed.mukinilk-kkr@mq

Steering committee

(QMB)Heike Richthammer (Leiterin QM), Frank Löscher (Geschäftsführer)

Conference frequency: wöchentlich

Risk management

Responsible person

Leiterin Qualitätsmanagement

Heike Richthammer

Phone: 0761-2711-2264
Fax: 0761-2711-782264
Mail: ed.mukinilk-kkr@mq

Steering committee

(QMB)Heike Richthammer (Leiterin QM), Frank Löscher (Geschäftsführer)

Conference frequency: wöchentlich

Risk management instruments and measures

Instruments and measures

No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Dokumentationswesen AKF (08.11.2022)
RM02	Regular further education and training measures
RM04	Clinical emergency management Dokumentationswesen AKF (08.11.2022)
RM05	Pain management Dokumentationswesen AKF (08.11.2022)
RM06	Fall prophylaxis Dokumentationswesen AKF (08.11.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dokumentationswesen AKF (08.11.2022)
RM08	Regulated handling of custodial measures Dokumentationswesen AKF (08.11.2022)
RM09	Regulated handling of occurring malfunctions of devices Dokumentationswesen AKF (08.11.2022)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Pathologiebesprechungen Palliativbesprechungen Qualitätszirkel Komplikationsbesprechung
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 Dokumentationswesen AKF (08.11.2022)
RM15	Preoperative, complete presentation of necessary findings Dokumentationswesen AKF (08.11.2022)
RM16	Procedure to avoid procedural and patient mix-ups Dokumentationswesen AKF (08.11.2022)
RM17	Standards for recovery and postoperative care Dokumentationswesen AKF (08.11.2022)
RM18	Discharge management Dokumentationswesen AKF (08.11.2022)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: bei Bedarf

Measures

Direkte Information an die betroffenen Bereiche im Bedarfsfall

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 14.08.2018
IF02	Internal evaluation of the received reports taken quartalsweise
IF03	Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken bei Bedarf

No.

Explanation

IF01

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

As of: 14.08.2018

IF02

Internal evaluation of the received reports

taken quartalsweise

IF03

Training of employees in handling the error reporting system and in implementing the findings from the error reporting system

taken bei Bedarf

Across all institutions

Conference committee

Conference frequency: bei Bedarf

No.	Explanation
EF01	CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association, National Association of Statutory Health Insurance Doctors)
EF03	KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors)