Dealing with risks in patient care
Quality management
Barbara Kroiß
Qualitätsmanagementbeauftragte
Mozartstraße 14a-16
80336 München
Phone:
089
-51409-180
Mail:
ed.demetra@ssiork.arabrab
Es findet im Rahmen eines im 14 Tage Rhythmus stattfindenden Jour Fixe ein Austausch zwischen QMB und Klinikleitung statt. Hierbei werden alle Fragen im Bereich Qualitätsmanagement erörtert. Darüberhinaus tagt das QM-Gremium in quartalsweisen Abständen.
Conference frequency: quartalsweise
Risk management
Annette Klein
Fachärztin für Dermatochirurgie
Phone:
089
-51409-170
Fax: 089-51409-167
Mail:
ed.demetra@nielk.ettenna
Besprechungen finden, insbesondere zu CIRS, zwischen ärztlichen Bereich, Klinikleitung und QMB statt.
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Verfahrensanweisung CIRS, Meldebogen CIRS (19.02.2020) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management VA_Umgang mit lebensbedrohlichen Situationen (Stand: 10/23), VA_CIRS (Stand: 02/20), Meldebogen CIRS (Stand: 02/20) (09.10.2023) |
| RM05 |
Pain management Verfahrensanweisung CIRS, Meldebogen CIRS (19.02.2020) |
| RM06 |
Fall prophylaxis Verfahrensanweisung CIRS, Meldebogen CIRS (19.02.2020) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Verfahrensanweisung CIRS, Meldebogen CIRS (19.02.2020) |
| RM08 |
Regulated handling of custodial measures Einwilligung zur Bettfixierung (27.02.2020) |
| RM09 |
Regulated handling of occurring malfunctions of devices Verfahrensanweisung CIRS, Meldebogen CIRS (19.02.2020) |
| 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 Verfahrensanweisung CIRS, Meldebogen CIRS (19.02.2020) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Verfahrensanweisung CIRS, Meldebogen CIRS (19.02.2020) |
| RM17 |
Standards for recovery and postoperative care Verfahrensanweisung CIRS, Meldebogen CIRS (19.02.2020) |
| RM18 |
Discharge management Verfahrensanweisung CIRS, Meldebogen CIRS (19.02.2020) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
CIRS
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 19.02.2020 |
| IF02 |
Internal evaluation of the received reports taken bei Bedarf |
| 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: