Dealing with risks in patient care
Quality management
Herr Dr. Matthias Müller
Medizinischer Direktor
An der Lutter 24
37075 Göttingen
Phone:
0551
-5034-1181
Mail:
ed.edneewke@mq
Der QM-Lenkungskreis besteht aus 13 Personen aus den Bereichen: Med. Geschäftsführung, Qualitätsmanagement, Medizincontrolling, Arzt- und Pflegedienst, Beschwerdemanagement, Mitarbeitervertretung, Sozial- und Entl.management und Krankenhaushygiene. Bei Bedarf werden Gäste zu den Treffen eingeladen.
Conference frequency: halbjährlich
Risk management
Matthias Müller
Medizinsicher Direktor
An der Lutter 24
37075 Göttingen
Phone:
0551
-5034-1181
Fax: 0551-5034-1514
Mail:
ed.edneewke@tkatnok
Der Arbeitskreis Risikomanagement besteht aus Mitarbeitern der Bereiche: Direktorium, Qualitätsmanagement, Arzt- und Pflegedienst, Beschwerdemanagement, Schadensfallmanagement, Arbeitssicherheit, Krankenhaushygiene. Der AK trifft sich 3x jährlich.
Conference frequency: andere Frequenz
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available roXtra (30.08.2024) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management roXtra (30.08.2024) |
| RM05 |
Pain management roXtra (30.08.2024) |
| RM06 |
Fall prophylaxis roXtra (30.08.2024) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) roXtra (30.08.2024) |
| RM08 |
Regulated handling of custodial measures roXtra (30.08.2024) |
| RM09 |
Regulated handling of occurring malfunctions of devices roXtra (30.08.2024) |
| 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 roXtra (30.08.2024) |
| RM15 |
Preoperative, complete presentation of necessary findings roXtra (30.08.2024) |
| RM16 |
Procedure to avoid procedural and patient mix-ups OP-Statut (22.03.2023) |
| RM17 |
Standards for recovery and postoperative care roXtra (30.08.2024) |
| RM18 |
Discharge management roXtra (30.08.2024) |
Fault reporting systems
Conference committee
Conference frequency: wöchentlich
Measures
Die eingehenden Meldungen werden zeitnah vom Team des QM gesichtet, ggf. anonymisiert und fachlich versierten Spezialisten (Ärzte, Pflegekräfte, Krankenhaushygiene, ...) zur Analyse und Bewertung weitergeleitet. Es werden konkrete Handlungsmaßnahmen zur Erhöhung der Patientensicherheit abgeleitet und z.B. in Form einer SOP/Dienstanweisung in das bestehende QM - System implementiert.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 06.05.2024 |
| 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 monatlich |
Conference committee
Conference frequency: monatlich
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |
| EF14 |
CIRS Health Care |