Dealing with risks in patient care
Quality management
Irma Heine-Penning
Qualitätsmanagement
Zeppelinstrasse 21
78532 Tuttlingen
Phone:
07461
-97-1600
Mail:
ed.tut-mukinilk@gninneP-enieH.I
Geschäftsführung Personaldirektion Verwaltungsdirektion ärztlicher Direktor Pflegedirektion Leitung Qualitätsmanagement Chefärzte
Conference frequency: monatlich
Risk management
Irma Heine-Penning
Qualitätsmanagement
Zeppelinstrasse 21
78532 Tuttlingen
Phone:
07461
-97-1600
Fax: 07461-97-51600
Mail:
ed.tut-mukinilk@gninneP-enieH.I
Geschäftsführung Personaldirektion Verwaltungsdirektion ärztlicher Direktor Pflegedirektion Leitung Qualitätsmanagement Chefärzte
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Mortalitäts- und Morbiditätskonferenzen, Pathologiebesprechungen, Qualitätszirkel (28.06.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management VA Notfallmanagement SOP Arzt Notfallteam alarmieren AA Notfall Ablauf Reanimation TUT/SPA Leitlinien Reanimation 2021 GRC Alarmplan Intranet (28.06.2023) |
| RM05 |
Pain management Schmerzmanagementhandbuch (25.01.2023) |
| RM06 |
Fall prophylaxis SOP Sturzmanagement Expertenstandard Sturzprophylaxe Flyer Vermeiden von Stürzen, Information für Pat. und Angehörige (15.05.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitusprophylaxe Dekubituseinschätzung nach Braden VA Dekubitusmanagement (26.06.2022) |
| RM08 |
Regulated handling of custodial measures DA Freiheitsentziehende Maßnahmen SOP Fiexierung Freiheitsentzieehende Maßnahme (31.07.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices DA Organisationshandbuch Medizintechnik (05.12.2022) |
| 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 OP Statut (20.07.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings Sicherheitscheckliste OP (20.06.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups VA Umgang mit Patientenidentifikationsarmband Sicherheitscheckliste OP Handbuch Neugeborene (01.06.2022) |
| RM17 |
Standards for recovery and postoperative care Aufwachraumprotokoll Überwachungsprotokoll Station (01.02.2023) |
| RM18 |
Discharge management DA Interdisziplinäres Entlassmanagement (19.05.2022) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Meldewesen im Intranet
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 28.06.2023 |
| 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 jährlich |
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) |