Dealing with risks in patient care

Quality management

Kristin Michallik

Referentin der Geschäftsführung

Eitzer Straße 20
27283 Verden (Aller)

Phone: 04231 -103-5021
Mail: ed.kinilk-resew-rella@killahcim.k

Geschäftsführung / Krankenhausleitung / Qualitätsmanagement

Conference frequency: monatlich

Risk management

Kristiane Langer

Externe Risikomanagerin

Eitzer Straße 20
27283 Verden (Aller)

Phone: 04231 -103-5000
Fax: 04231-103-7340
Mail: ed.kinilk-resew-rella@regnal.k

Geschäftsführung / Ärztlicher Direktor / Pflegedirektion / Verwaltungsdirektion / externe Risikomanagerin, Qualitätsmanagerin

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

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

Strategiepapier Risikomanagement (2016) (15.09.2022)

RM02

Regular further education and training measures

RM04

Clinical emergency management

VA Notfallmanagement - Konzept innerklinischer Notfall 2021 (15.04.2021)

RM05

Pain management

Schmerzstandard zur Behandlung akuter Schmerzen und Schema Schmerztherapie (11.03.2020)

RM06

Fall prophylaxis

VA Umgang mit Stürzen (08.05.2019)

RM07

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

VA Dekubitusprophylaxe (08.05.2019)

RM08

Regulated handling of custodial measures

AWK VA Freiheitsentziehende Maßnahmen, inkl. Fixierungsprotokoll (07.08.2020)

RM09

Regulated handling of occurring malfunctions of devices

VA Umgang mit Medizinprodukten (20.03.2021)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Mortalitäts- und Morbiditätskonferenzen
  • Fachanalysen nach London Protocol
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

VA Team-Time-Out und Perioperative Checkliste / OP-Statut (08.01.2019)

RM15

Preoperative, complete presentation of necessary findings

VA Team-Time-Out und Perioperative Checkliste (Team-Time-Out -Checkliste) (01.04.2020)

RM16

Procedure to avoid procedural and patient mix-ups

VA Identifikationsarmband, VA Vermeidung von Verwechslungen im OP (24.09.2020)

RM17

Standards for recovery and postoperative care

Aufwachraumstandards, postoperative Überwachung, AA Verlegung AWR (1.0) (15.06.2021)

RM18

Discharge management

VA Entlassung (4.0) (08.03.2018)

Fault reporting systems

Conference committee

Conference frequency: quartalsweise

Measures

Klinikbezogene CIRS-Gruppen (eine berufsgruppenübergreifend besetzte Gruppe pro Fachklinik

No. Explanation
IF01

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

As of: 22.01.2018

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 quartalsweise

Conference committee

Conference frequency: monatlich

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)