Dealing with risks in patient care

Quality management

Anna-Lena Kossek

Qualitätsmanagementbeauftragte

Dohuser Weg 10
26409 Wittmund

Phone: 04462 -86-2130
Mail: ed.mtw-hk@kessok.anel-anna

Anna-Lena Kossek

Qualitätsmanagementbeauftragte

Dohuser Weg 10
26409 Wittmund

Phone: 04462 -86-2130
Mail: ed.mtw-hk@kessok.anel-anna

interdisziplinäre Qualitätszirkel

Conference frequency: bei Bedarf

Risk management

Christina de Vries

Risikomanager

Dohuser weg 10
26409 Wittmund

Phone: 04462 -86-2124
Fax: 04462-86-42124
Mail: ed.mtw-hk@seirved.anitsirhc

interdisziplinäre Qualitätszirkel

Conference frequency: bei Bedarf

Risk management instruments and measures

No. Explanation
RM01

Comprehensive quality and/or risk management documentation (QM/RM documentation) is available

Risikomanagementhandbuch (03.02.2023)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Qualitätsmanagementhandbuch / VA Notfallmanagement / VA Reanimationsablauf / VA Notfallmanagement OP (01.09.2021)

RM05

Pain management

modifizierter Expertenstandard Schmerzmanagement in der Pflege Schmerzstandard (01.10.2019)

RM06

Fall prophylaxis

modifizierter Expertenstandard Sturzprophylaxe in der Pflege (15.05.2022)

RM07

Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”)

modifizierter Expertenstandard Dekubitusprophylaxe in der Pflege (27.05.2022)

RM08

Regulated handling of custodial measures

VA Betreuung_Fixierung (01.08.2020)

RM09

Regulated handling of occurring malfunctions of devices

Qualitätsmanagementhandbuch, Dienstanweisung zur Anwendung von Medizinprodukten (01.05.2017)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Mortalitäts- und Morbiditätskonferenzen
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

Qualitätsmanagementhandbuch / WHO Checkliste / Patient Blood Management (16.05.2023)

RM15

Preoperative, complete presentation of necessary findings

VA allgemeine Fallbesprechung (01.12.2021)

RM16

Procedure to avoid procedural and patient mix-ups

Qualitätsmanagementhandbuch / WHO-Checkliste / Patientenarmbänder (01.01.2019)

RM17

Standards for recovery and postoperative care

Qualitätsmanagementhandbuch / Behandlungspfade / Pflegestandards postoperative Versorgung (01.08.2022)

RM18

Discharge management

Qualitätsmanagementhandbuch (01.09.2019)

Fault reporting systems

Conference committee

Conference frequency: bei Bedarf

Measures

EDV-gestützte Medikationsanordnungen, Absicherungen von Zuwegungen, Anpassung der Ausgabe von Blutprodukten

No. Explanation
IF01

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

As of: 28.02.2020

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: bei Bedarf

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)