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Städtisches Klinikum Dresden - Standort Friedrichstadt

Dealing with risks in patient care

Quality management

Responsible person

Herr Thomas Prickartz

Leiter Qualitätsmanagement

Friedrichstraße 41
01067 Dresden

Phone: 0351 -480-3065
Mail: ed.nedserd-mukinilk@mq

Steering committee

Das Lenkungsgremium setzt sich neben den Mitarbeitern des zentralen Qualitätsmanagements aus QM-Beauftragten Mitarbeitern verschiedener Abteilungen/Kliniken zusammen. Das Gremium ist hierarchieübergreifend und interdisziplinär besetzt.

Conference frequency: quartalsweise

Risk management

Responsible person

Thomas Prickartz

Leiter Qualitätsmanagement

01067 Dresden

Phone: 0351 -480-3065
Fax: 0351-480-4271
Mail: ed.nedserd-mukinilk@mq

Steering committee

CIRS-Team mit geschulten Mitarbeitern und interdisziplinärer Besetzung. Die Einbeziehung der Krankenhausleitung erfolgt bei Bedarf.

Conference frequency: quartalsweise

Risk management instruments and measures

Instruments and measures

No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Handbuch zum klinischen Risikomanagement (28.08.2024)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Handbuch zum klinischen Risikomanagement (28.08.2024)
RM05	Pain management Teil der Pflegestandards (01.03.2022)
RM06	Fall prophylaxis Teil der Pflegestandards (17.01.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Teil der Pflegestandards (17.01.2022)
RM08	Regulated handling of custodial measures Teil der Pflegestandards (01.03.2022)
RM09	Regulated handling of occurring malfunctions of devices Handbuch zum klinischen Risikomanagement (28.08.2024)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Pathologiebesprechungen Palliativbesprechungen Qualitätszirkel
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 Handbuch zum klinischen Risikomanagement (28.08.2024)
RM15	Preoperative, complete presentation of necessary findings Handbuch zum klinischen Risikomanagement (28.08.2024)
RM16	Procedure to avoid procedural and patient mix-ups Handbuch zum klinischen Risikomanagement (28.08.2024)
RM17	Standards for recovery and postoperative care Handbuch zum klinischen Risikomanagement (28.08.2024)
RM18	Discharge management Handbuch zum Qualitäts- und klinischen Risikomanagement (01.07.2022)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: bei Bedarf

Measures

Verbesserungsmaßnahmen werden mindestens einmal im Quartal bei Bedarf abgeleitet.

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 28.08.2024
IF02	Internal evaluation of the received reports taken quartalsweise
IF03	Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken quartalsweise

No.

Explanation

IF01

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

As of: 28.08.2024

IF02

Internal evaluation of the received reports

taken quartalsweise

IF03

Training of employees in handling the error reporting system and in implementing the findings from the error reporting system

taken quartalsweise

Across all institutions

Conference committee

Conference frequency: quartalsweise

No.	Explanation
EF15	PaSIS (Patient Safety and Information System of the University Hospital Tübingen)