Dealing with risks in patient care

Quality management

Dr. Hans-Henning Nölcke

Leitung Qualitätsmanagement

Am Krankenhaus 1
21614 Buxtehude

Phone: 04141 -97-1686
Mail: ed.nekinilkeble@ekcleoN.gninneH

Geschäftsführung Betriebsleiter Ärztliche Direktoren Pflegedirektion Bereichsleiter Qualitätsmanagement

Conference frequency: halbjährlich

Risk management

Michael Albers

Sicherheits- und Risikomanager

Am Krankenhaus 1
21614 Buxtehude

Phone: 04141 -97-1078
Fax: 04141-97-1084
Mail: ed.nekinilkeble@srebla.leahcim

Chefarztkonferenz

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

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

Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015)

RM02

Regular further education and training measures

RM04

Clinical emergency management

Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015)

RM05

Pain management

Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015)

RM06

Fall prophylaxis

Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015)

RM07

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

Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015)

RM08

Regulated handling of custodial measures

Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015)

RM09

Regulated handling of occurring malfunctions of devices

Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Pathologiebesprechungen
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

Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015)

RM15

Preoperative, complete presentation of necessary findings

Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015)

RM16

Procedure to avoid procedural and patient mix-ups

Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015)

RM17

Standards for recovery and postoperative care

Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015)

RM18

Discharge management

Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (16.04.2015)

Fault reporting systems

Conference committee

Conference frequency: bei Bedarf

Measures

Pflichtfortbildungen für Ärzte und Pflege

No. Explanation
IF01

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

As of: 02.02.2015

IF02

Internal evaluation of the received reports

taken quartalsweise

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: halbjährlich

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)