Dealing with risks in patient care
Quality management
Dolores Preiß
Qualitätsmanagementbeauftragte
Ansbacher Str. 131
91541 Rothenburg
Phone:
09861
-707-0
Mail:
ed.demoigerna@kitirkdnubol
Vorstand / Klinikdirektor:innen / Ärztliche Direktor:in/ Pflegedirektor / DLZ QRM / DLZ Leitungen (Leitungskonferenz)
Conference frequency: quartalsweise
Risk management
Heike Landshuter
Qualitätsmanagementbeauftragte / Risikomanager
Phone:
0981
-484-0
Mail:
ed.demoigerna@kitirkdnubol
Conference frequency:
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available VA Handbuch Risikomanagement/ VA Dokumentenlenkung (23.01.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management KD VA Alarm-und Einsatzplan Abschnitt A, Abschnitt BI, Abschnitt BII, Abschnitt C, Anhang Alatmierungslisten, Anhang AuftragsblätterÄD VA Notfallmanagement Verfahrensanweisungen zu verschiedenen klinischen Notfällen, z.B. auch: Kardiogener Schock, Hypertensive Krise, Schenkelhalsfraktur (30.05.2022) |
| RM05 |
Pain management ANÄ FO Analgesie-und Behandlungspfade (24.05.2022) |
| RM06 |
Fall prophylaxis Expertenstandard Sturz (08.08.2024) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitusprophylaxe (08.08.2024) |
| RM08 |
Regulated handling of custodial measures VA Freiheitsentziehende Maßnahmen (14.05.2024) |
| RM09 |
Regulated handling of occurring malfunctions of devices Handbuch Organisationshandbuch Medizintechnik ANregiomed- Einrichten, Instandhalten, Betreiben, Anwenden, Verantwortlichkeiten; DA Strahlenschutzanweisungen Abt. (15.07.2024) |
| 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 CL Prävention von Eingriffsverwechslungen mit Teame-time-out (07.03.2024) |
| RM15 |
Preoperative, complete presentation of necessary findings DA OP-Statut (20.08.2020) |
| RM16 |
Procedure to avoid procedural and patient mix-ups CL Prävention von Eingriffsverwechslungen mit Teame-time-out (07.03.2024) |
| RM17 |
Standards for recovery and postoperative care SOP Betreuung im Aufwachraum (14.08.2024) |
| RM18 |
Discharge management VA Entlassmanagement (15.04.2024) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Prüfung ggf. Anpassung der SOP's;Veröffentlichung bzw. Schulung der Maßnahme zur Verbesserung der Patientensicherheit
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 04.07.2023 |
| IF02 |
Internal evaluation of the received reports taken halbjährlich |
| 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 Association, German Nursing Council, German Medical Association) |