Dealing with risks in patient care

Quality management

Miriam Haubold

Qualitätsmanagementbeauftragte

Zeisigwaldstraße 101
09130 Chemnitz

Phone: 0371 -430-1038
Mail: ed.nocaide@dlobuah.mairim

Geschäftsführung, Pflegedirektion, ärztliche Direktion, QM

Conference frequency: quartalsweise

Risk management

Peter Wolf

ärztlicher Direktor

Zeisigwaldstraße 101
09130 Chemnitz

Phone: 0371 -430-1236
Fax: 0371-430-1204
Mail: ed.nocaide@flow.retep

Geschäftsführung, Pflegedirektion, ärztliche Direktion, QM

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

Risikomanagementhandbuch (01.01.2020)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Verfahrensanweisung Medizinisches Notfallmanagement (27.03.2023)

RM05

Pain management

Verfahrensanweisung Schmerzmanagement in der Pflege (26.06.2023)

RM06

Fall prophylaxis

VA Sturzmanagement (18.03.2019)

RM07

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

Verfahrensanweisung Dekubitusmanagement (21.02.2011)

RM08

Regulated handling of custodial measures

Verfahrensanweisung Patientensicherheit und Fixierung (28.02.2022)

RM09

Regulated handling of occurring malfunctions of devices

AGA AMTech Handbuch Medizintechnik (01.07.2021)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
RM12

Use of standardised information sheets

RM13

Application of standardised surgical check lists

RM15

Preoperative, complete presentation of necessary findings

OP-Statut (19.03.2021)

RM16

Procedure to avoid procedural and patient mix-ups

Empfehlungen für Patientensicherheit + OP-Statut (19.03.2021)

RM17

Standards for recovery and postoperative care

Standards und Checklisten Aufwachraum (27.03.2023)

RM18

Discharge management

Verfahrensanweisung Entlassmanagement (01.05.2022)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

CIRS

No. Explanation
IF01

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

As of: 04.09.2023

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 bei Bedarf

Conference committee

Conference frequency: monatlich

No. Explanation

Other