Ilm-Kreis-Kliniken Arnstadt-Ilmenau gGmbH

Dealing with risks in patient care

Quality management

Stefanie Jecht

Qualitäts- und Risikomanagement

Bärwinkelstraße 33
99310 Arnstadt

Phone: 03628-919-405
Mail: ed.nekinilk-sierk-mli@thceJ.einafetS

Maria Daniela Murach

Qualitäts- und Risikomanagement

Bärwinkelstraße 33
99310 Arnstadt

Phone: 03628-919-405
Mail: ed.nekinilk-sierk-mli@hcaruM.aleinaDairaM

Geschäftsführung, Ärztlicher Dienst, Pflege, Funktionsdienst, Verwaltung

Conference frequency: quartalsweise

Risk management

Qualitäts- und Risikomanagement

Stefanie Jecht

Phone: 03628-919-405
Fax: 03628-919-403
Mail: ed.nekinilk-sierk-mli@thceJ.einafetS

Qualitäts- und Risikomanagement

Maria Daniela Murach

Phone: 03628-919-405
Fax: 03628-919-403
Mail: ed.nekinilk-sierk-mli@hcaruM.aleinaDairaM

Geschäftsführung, Ärztlicher Dienst, Pflege, Funktionsdienst, Verwaltung

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

Teil der QM/RM-Dokumentation (30.11.2020)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Teil der QM/RM-Dokumentation (30.11.2020)

RM05

Pain management

Teil der QM/RM-Dokumentation (30.11.2020)

RM06

Fall prophylaxis

Teil der QM/RM-Dokumentation (30.11.2020)

RM07

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

Teil der QM/RM-Dokumentation (30.11.2020)

RM08

Regulated handling of custodial measures

Teil der QM/RM-Dokumentation (30.11.2020)

RM09

Regulated handling of occurring malfunctions of devices

Teil der QM/RM-Dokumentation (30.11.2020)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Pathologiebesprechungen
  • Palliativbesprechungen
  • Qualitätszirkel
  • Fallbesprechungen
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

Teil der QM/RM-Dokumentation (30.11.2020)

RM15

Preoperative, complete presentation of necessary findings

Teil der QM/RM-Dokumentation (30.11.2020)

RM16

Procedure to avoid procedural and patient mix-ups

Teil der QM/RM-Dokumentation (30.11.2020)

RM17

Standards for recovery and postoperative care

Teil der QM/RM-Dokumentation (30.11.2020)

RM18

Discharge management

Teil der QM/RM-Dokumentation (30.11.2020)

Fault reporting systems

Conference committee

Conference frequency: quartalsweise

Measures

Prozessaudits in den Bereichen, Anpassung der Dienstanweisung Dokumentation, Einführung eines Softwaremoduls zum Meldewesen


No. Explanation
IF01

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

As of: 22.06.2020

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)