Dealing with risks in patient care
Quality management
Christine Niebler
Leitung Qualitäts-, Beschwerde- und Projektmanagement
Mariahilfbergweg 7
92224 Amberg
Phone:
09621
-38-4064
Mail:
ed.grebma-mukinilk@enitsirhc.relbein
Vorstand, Qualitätsmanagement
Conference frequency: monatlich
Risk management
Harald Hollnberger
Ärztl. Direktor
Phone:
09621
-38-1909
Fax: 09621-38-1900
Mail:
ed.grebma-mukinilk@dlarah.regrebnlloh
Vorstand, Leitungskonferenz, Risikomanagement, Informationssicherheitsbeauftragter/ISMS-Koordinator, Technischer Leiter, Leiter Med. Technik, Leiter IT, Personalratsvorsitzender
Conference frequency: halbjährlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Interne Audits am KSM - Regelmäßig stattfindende interne Audits werden im Programm Anaquestra dokumentiert und ggf. Maßnahmenlisten generiert und die Abarbeitung der Maßnahmen verfolgt. (29.03.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Reanimation bei Kreislaufstillstand ReaTeam (31.08.2022) |
| RM05 |
Pain management Schmerzmanagement Algorithmus (30.10.2023) |
| RM06 |
Fall prophylaxis Sturzprophylaxe Pflegestandard (21.12.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusprophylaxe nach Expertenstandard (11.03.2022) |
| RM08 |
Regulated handling of custodial measures Standard Fixierungen und Alternativen (04.07.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Dienstanweisung zu MPG und MPBetreibV (Medizintechnik) (13.03.2023) |
| 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 OP-Checkliste (18.04.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings Voruntersuchungen zur Narkose (15.07.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Verfahrensanweisung Patientenidentifikationsarmbänder (12.12.2023) |
| RM17 |
Standards for recovery and postoperative care Standard zur postoperativen pflegerischen Versorgung des Patienten (16.01.2023) |
| RM18 |
Discharge management Verfahrensanweisung Entlassmanagement (07.10.2022) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
diverse
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 15.11.2023 |
| IF02 |
Internal evaluation of the received reports taken jährlich |
| 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: quartalsweise
| No. | Explanation |
|---|---|
|
Other |
|
| EF01 |
CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association) |
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |