Dealing with risks in patient care
Quality management
Christine Wölk
Zentrale Dienste Prozess- und Qualitätsmanagement
Lindenstraße 2
39291 Lostau
Phone:
0391
-8505-767
Mail:
ed.negnutfits-ehcsreffiefp@mqp
Christine Wölk
Zentrale Dienste Prozess- und Qualitätsmanagement
Lindenstraße 2
39291 Lostau
Phone:
0391
-8505-767
Mail:
ed.negnutfits-ehcsreffiefp@mqp
Geschäftsführung, Verwaltungsleitung, Ärztlicher Direktor, Pflegedienstleitung, Qualitätsbeauftragte
Conference frequency: quartalsweise
Risk management
Christine Wölk
Zentrale Dienste Prozess- und Qualitätsmanagement
Lindenstraße 2
39291 Lostau
Phone:
0391
-8505-767
Fax: 0391-8505-9980
Mail:
ed.negnutfits-ehcsreffiefp@mqp
Christine Wölk
Zentrale Dienste Prozess- und Qualitätsmanagement
Lindenstraße 2
39291 Lostau
Phone:
0391
-8505-767
Fax: 0391-8505-9980
Mail:
ed.negnutfits-ehcsreffiefp@mqp
Mitarbeiter ärztlicher Dienst, Mitarbeiter Pflege, Hygienebeauftragte, Qualitätsbeauftragte
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Geschäftsordnung Critical Incident Reporting System riskop, Dienstanweisung Chancen- und Risikomanagement (23.05.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management diverse Dokumente zum Notfallmanagement (14.04.2022) |
| RM05 |
Pain management Expertenstandard akute Schmerzen, Expertenstandard chronische Schmerzen, (07.07.2022) |
| RM06 |
Fall prophylaxis Expertenstandard Sturzprophylaxe (12.05.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitusprophylaxe (07.07.2022) |
| RM08 |
Regulated handling of custodial measures Verfahrensanweisung freiheitsentziehende Maßnahmen (09.05.2019) |
| RM09 |
Regulated handling of occurring malfunctions of devices Umgang mit defekten Medizinprodukten (03.05.2023) |
| 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-Dokumentation KIS (14.10.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings OP-Dokumentation KIS (14.10.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Patientenidentifikation (01.03.2023) |
| RM17 |
Standards for recovery and postoperative care diverse Anweisungen vorhanden (13.09.2022) |
| RM18 |
Discharge management Entlassmanagement (11.05.2023) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Erhöhung der Sicherheit durch verbesserte Medikamentenbeschriftung, Initiierung von Schulungsmaßnahmen, Einführung von Patientenarmbändern, Verbesserung hygienischer Standards
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 28.07.2023 |
| 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: bei Bedarf
| No. | Explanation |
|---|---|
| EF02 |
CIRS Berlin (Medical Association Berlin, German Medical Association, National Association of Statutory Health Insurance Doctors) |