Dealing with risks in patient care

Quality management

Claudia Luippold

QM-Beauftragte

Paul-Lechler-Straße 26
72076 Tübingen

Phone: 07071 -206457-
Mail: ed.kinilkneport@dloppiul

Geschäftsführung, Pflegedienstleitung, ärztliche Leitung, Mitarbeitervertretung

Conference frequency: monatlich

Risk management

Claudia Luippold

QM-Beauftragte


72076 Tübingen

Phone: 07071 -206457-
Mail: ed.kinilkneport@dloppiul

Geschäftsführung, Pflegedienstleitung, ärztliche Leitung, Mitarbeitervertretung

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

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

QM-Handbuch, DIN ISO 9001-2015 (25.05.2023)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Alarmplan, Notfallalarmierungsplan, Notfallstruktur (14.04.2022)

RM05

Pain management

Schmerzmanagement in der Pflege (29.07.2021)

RM06

Fall prophylaxis

Sturzprophylaxe und Risikofaktoren (23.12.2022)

RM07

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

Standard Dekubitusprophylaxe (07.04.2022)

RM08

Regulated handling of custodial measures

Durchführung von FEM (22.06.2022)

RM09

Regulated handling of occurring malfunctions of devices

Meldeweg Vorkommnisse mit Medizinprodukten (03.03.2022)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Mortalitäts- und Morbiditätskonferenzen
  • Palliativbesprechungen
  • interdisziplinäres Team Akut-Geriatrie
RM12

Use of standardised information sheets

RM16

Procedure to avoid procedural and patient mix-ups

Handbuch Qualitätsmanagement (25.05.2023)

RM18

Discharge management

Entlassungsmanagement (21.01.2021)

Fault reporting systems

Conference committee

Conference frequency: quartalsweise

Measures

Einführung E-Pflegeprozess, E-Wunddokumentation,

No. Explanation
IF01

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

As of: 23.05.2023

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: quartalsweise

No. Explanation
EF03

KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors)