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KRH Klinikum Siloah

Dealing with risks in patient care

Quality management

Responsible person

Frau Carsta Seidel

Qualitätsmanagerin

Stadionbrücke 4
30459 Hannover

Phone: 0511 -927-7543
Mail: ed.hrk@ledies.atsrac

Steering committee

interdisziplinärer Qualitätszirkel, je Organkrebszentrum und im Krebszentrum, Interne Steuerungsgruppen, Berufsgruppenvertretungen, standortbezogenen Qualitätszirkel onkologische Fachpflege und standortübergreifend Qualitätsmultiplikatoren Treffen, Organisationsentwicklungstreffen

Conference frequency: monatlich

Risk management

Responsible person

Carsta Seidel

Risikomanagerin

Phone: 0511 -927-7543
Fax: 0511-927-976683
Mail: ed.hrk@ledies.atsrac

Steering committee

Zentrale Steuerungsgruppe

Conference frequency: jährlich

Risk management instruments and measures

Instruments and measures

No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available RM 01 Dokumentenlenkungssystem (DLS) 01.07.2019 (01.07.2019)
RM02	Regular further education and training measures
RM04	Clinical emergency management Teil der QM/RM Dokumentation (gemäß RM01) RM 04 Dokumentenlenkung (DLS) 01.07.2019 (01.07.2019)
RM05	Pain management RM 05 (02.03.2022)
RM06	Fall prophylaxis RM 06 (02.03.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) RM 07 (02.03.2022)
RM08	Regulated handling of custodial measures RM 08 (06.04.2022)
RM09	Regulated handling of occurring malfunctions of devices RM 09 (06.05.2022)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Palliativbesprechungen Qualitätszirkel
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 RM 01 Dokumentenlenkungssystem (DLS) 01.07.2019 (01.07.2019)
RM15	Preoperative, complete presentation of necessary findings RM 15 (02.11.2021)
RM16	Procedure to avoid procedural and patient mix-ups RM 16 (02.11.2021)
RM17	Standards for recovery and postoperative care RM 17 (04.11.2021)
RM18	Discharge management RM 18 (03.11.2021)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

CIRS vollumfänglich eingeführt für das gesamte KRH Verfahren für Meldungen; Besondere Vorkommnisse im gesamten KRH etabliert

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 15.11.2022
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 quartalsweise

No.

Explanation

IF01

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

As of: 15.11.2022

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 quartalsweise

Across all institutions

Conference committee

Conference frequency:

No.	Explanation
	Other
EF01	CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association)

No.

Explanation

Other

EF01

CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association)