QM-Lenkungsgremium (Stabsstelle QM + Krankenhausleitung) und QM-Arbeitskreis (Stabsstelle QM + interdisziplinäre Teilnehmende)
Conference frequency: monatlich
Ltr. QM
Andreas Kelpe
Pfafferode 102
99974 Mühlhausen
Phone: 03601-803-841
Fax: 03601-803-266
Mail: ed.kheo@eplek.a
QM-Lenkungsgremium (Stabsstelle QM + Krankenhausleitung) und QM-Arbeitskreis (Stabsstelle QM + interdisziplinäre Teilnehmende)
Conference frequency: monatlich
No. | Explanation |
---|---|
RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available VA Risikomanagement (D1015) (18.07.2021) |
RM02 |
Regular further education and training measures |
RM04 |
Clinical emergency management VA Medizinisches Notfallkonzept (D3946) (18.02.2022) |
RM05 |
Pain management VA Schmerztherapie (D1611) (01.03.2018) |
RM06 |
Fall prophylaxis VA Sturzprophylaxe (D1767) (08.05.2018) |
RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) VA Dekubitusprophylaxe (D1113) (01.05.2018) |
RM08 |
Regulated handling of custodial measures VA Richtlinie zur Fixierung eines Patienten (D1666); VA Anordnung besondere Schutz und Sicherungsmaßnahmen (D531) (03.09.2018) |
RM09 |
Regulated handling of occurring malfunctions of devices VA Umgang mit Medizinprodukten (D2775) (12.10.2018) |
RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
RM12 |
Use of standardised information sheets |
RM18 |
Discharge management VA Entlassmanagement (D788) (01.03.2018) |
Conference frequency: monatlich
Etablierung: CIRS, Meinungsmanagement, Risikomanagement, medizinisches Notfallkonzept, Ausbau elektronischer Notfallmeldesysteme, Aufbau QM-Arbeitskreis
No. | Explanation |
---|---|
IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 18.07.2018 |
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 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) |