Dealing with risks in patient care

Quality management

Achim Schütz

Verwaltungsdirektor

Hermann-Löns-Straße 2
29451 Dannenberg

Phone: 05861 -83-0
Mail: ed.kejle@zteuhcS.mihcA

Qualitätsmanagementbeauftragte, Ärztlicher Direktor, Verwaltungsdirektor , Pflegedienstleitung und Betriebsrat

Conference frequency: quartalsweise

Risk management

Achim Schütz

Geschäftsführer

Phone: 05861 -83-0
Fax: 05861-83-1199
Mail: ed.kejle@zteuhcS.mihcA

Qualitätsmanagementbeauftragte, Ärztlicher Direktor, Verwaltungsdirektor , Pflegedienstleitung und Betriebsrat

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

QM System gemäß DIN Norm 9001:2015 fortlaufend (10.12.2018)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

QM System gemäß DIN Norm 9001:2015 fortlaufend (10.12.2018)

RM05

Pain management

QM System gemäß DIN Norm 9001:2015 fortlaufend (10.12.2018)

RM06

Fall prophylaxis

QM System gemäß DIN Norm 9001:2015 fortlaufend (10.12.2018)

RM07

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

QM System gemäß DIN Norm 9001:2015 fortlaufend (10.12.2018)

RM08

Regulated handling of custodial measures

QM System gemäß DIN Norm 9001:2015 fortlaufend (10.12.2018)

RM09

Regulated handling of occurring malfunctions of devices

QM System gemäß DIN Norm 9001:2015 fortlaufend (10.12.2018)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Mortalitäts- und Morbiditätskonferenzen
  • Palliativbesprechungen
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

QM System gemäß DIN Norm 9001:2015 fortlaufend (10.12.2018)

RM15

Preoperative, complete presentation of necessary findings

QM System gemäß DIN Norm 9001:2015 fortlaufend (10.12.2018)

RM16

Procedure to avoid procedural and patient mix-ups

QM System gemäß DIN Norm 9001:2015 fortlaufend (10.12.2018)

RM17

Standards for recovery and postoperative care

QM System gemäß DIN Norm 9001:2015 fortlaufend (10.12.2018)

RM18

Discharge management

QM System gemäß DIN Norm 9001:2015 fortlaufend (10.12.2018)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Anwendung von Patientenarmbändern zum Ausschluß von Verwechselungen

No. Explanation
IF01

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

As of: 07.08.2015

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
EF03

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