Dealing with risks in patient care

Quality management

Dr. Christina Ganz

Abteilungsleitung Prozess- und Qualitätsmanagement

Anna-von-Borries-Straße 1-7
30625 Hannover

Phone: 0511 -289-2038
Mail: ed.erevokaid@znag.anitsirhc

Medizinische Direktion Prozess- und Qualitätsmanagement

Conference frequency: wöchentlich

Risk management

Christina Ganz

Abteilungsleitung Prozess- und Qualitätsmanagement

Phone: 0511 -289-2038
Mail: ed.erevokaid@znag.anitsirhc

Medizinische Direktion Prozess- und Qualitätsmanagement

Conference frequency: wöchentlich

Risk management instruments and measures

No. Explanation
RM01

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

QM-Handbuch (24.10.2023)

RM02

Regular further education and training measures

RM04

Clinical emergency management

Teil der QM-Dokumentation (04.04.2022)

RM05

Pain management

Teil der QM-Dokumentation (09.08.2022)

RM06

Fall prophylaxis

Teil der QM-Dokumentation (30.03.2022)

RM07

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

Teil der QM-Dokumentation (30.03.2022)

RM08

Regulated handling of custodial measures

Teil der QM-Dokumentation (23.08.2023)

RM09

Regulated handling of occurring malfunctions of devices

Teil der QM-Dokumentation (03.04.2023)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Pathologiebesprechungen
  • Qualitätszirkel
RM12

Use of standardised information sheets

RM13

Application of standardised surgical check lists

RM16

Procedure to avoid procedural and patient mix-ups

Teil der QM-Dokumentation (31.03.2022)

RM18

Discharge management

Teil der QM-Dokumentation (27.07.2023)

Fault reporting systems

Conference committee

Conference frequency: bei Bedarf

Measures

Diverse medizinische und operative Prozesse insbesondere in den Bereichen Operation und Medikation verbessert

No. Explanation
IF01

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

As of: 05.04.2023

IF02

Internal evaluation of the received reports

taken bei Bedarf

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
EF14

CIRS Health Care