Dealing with risks in patient care
Quality management
Dipl.-Betriebsw. (FH) Silke Mühle-Peters
Stabsstelle QM
Steenbeker Weg 25
24106 Kiel
Phone:
0431
-388-82235
Mail:
ed.gnutfits-sunibul@sretep-elheum.s
Klinikleitungssitzung: Vorstand LC und SEK, Pflegedienstleitung/OP-Management, Controlling, Personalwesen, Finanzwesen, QM,IT, Marketing, Technik
Conference frequency: monatlich
Risk management
Silke Mühle-Peters
Stabsstelle QM
Phone:
0431
-388-82235
Fax: 0431-388-81290
Mail:
ed.gnutfits-sunibul@sretep-elheum.s
Steuerungsgruppe Themen Risikomanagement identisch zur Steuerungsgruppe QM sowie Fehlermeldesystem CIRSriskop - CIRS-Auswerteteam : Hygiene, Medizintechnik, OP- und Anästhesie, Station , QM; ITS
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 für LC/SEK in Nexus Curator - Einstellung aller aktuellen Dokumente für alle Fachbereiche/Abteilungen , CIRS "riskop" an den Standorten LC/SEK (04.09.2023) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Medizinisches Notfallmanagement (09.02.2022) |
| RM05 |
Pain management Schmerzkonzept (02.06.2022) |
| RM06 |
Fall prophylaxis VA Sturzprophylaxe (12.10.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) VA Dekubitusprophylaxe (16.11.2023) |
| RM08 |
Regulated handling of custodial measures VA Freiheitsentziehende Maßnahmen (28.11.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Op-Sicherheitscheckliste (28.11.2022) |
| 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 OP-Sicherheitscheckliste (28.11.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings OP-Sicherheitscheckliste und VA Umgang mit der OP-Sicherheitscheckliste (28.11.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups VA Patientenidentifikationsarmband (09.05.2022) |
| RM17 |
Standards for recovery and postoperative care VA Patientenverlegung aus OP bzw. AWR auf die Regelpflegestation (13.09.2022) |
| RM18 |
Discharge management VA Entlassmanagement (26.11.2022) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
bspw.: Schulung der Mitarbeiter:innen der Intensivstation durch Labor in Nutzung POCT-Geräte; Entwicklung von Dokumenten zum Prozessablauf Umgang mit Verstorbenen, Controlling OP-Sicherheitscheckliste /Seitenverwechslung
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 04.09.2022 |
| 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 bei Bedarf |
Conference committee
Conference frequency: monatlich
| No. | Explanation |
|---|---|
|
Other |