Dealing with risks in patient care
Quality management
Steffi Kapell
Qualitätsbeauftragte
Prenzlauer Chaussee 30
17309 Pasewalk
Phone:
03973
-23-1813
Mail:
moc.soipelksa@llepak.s
Geschäftsführung, Ärztliche Leitung, Pflegedienstleitung, Betriebsrat, Qualitätsmanagement
Conference frequency: monatlich
Risk management
Steffi Kapell
Qualitätsbeauftragte
Prenzlauer Chaussee 30
17309 Pasewalk
Phone:
03973
-23-1813
Fax: 03973-23-1425
Mail:
moc.soipelksa@llepak.s
Geschäftsführung, Ärztliche Leitung, Pflegedienstleitung, Betriebsrat, Qualitätsmanagement
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Konzept Klinisches Risikomanagement (15.01.2021) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Richtlinie Alarm- und Notfallplan (23.07.2018) |
| RM05 |
Pain management Konzept Schmerztherapie (17.08.2021) |
| RM06 |
Fall prophylaxis Pflegestandard Sturzprophylaxe (06.01.2020) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Prozess Dekubitusprophylaxe (28.06.2021) |
| RM08 |
Regulated handling of custodial measures Richtlinie Deeskalation und Fixierung (09.06.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices Organisationshandbuch Medizintechnik (15.08.2018) |
| 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 Sicherheit für OP-Patienten (25.05.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings Sicherheit für OP-Patienten (25.05.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups AKG-KGF-VA-33 Vermeidung einer Eingriffsverwechslung (24.02.2022) |
| RM17 |
Standards for recovery and postoperative care Diagnostik- und Therapierichtlinien der Fachabteilungen (28.06.2021) |
| RM18 |
Discharge management Prozess Entlassungsmanagement (26.07.2021) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
neue Benennung ärztliche Leitung der NFA mit entsprechenden Kompetenzen, Prozessanpassung Betreuung von Außenliegern, Dokumentationsanalysen mit Prozessanalysen und Verbesserungen
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 13.05.2020 |
| 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: monatlich
| No. | Explanation |
|---|---|
|
Other |
|
| EF14 |
CIRS Health Care |