Klinikum St. Marien Amberg

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)

Regular further education and training measures

Employee surveys

Clinical emergency management

Reanimation bei Kreislaufstillstand ReaTeam (31.08.2022)

Pain management

Schmerzmanagement Algorithmus (13.10.2021)

Fall prophylaxis

Sturzprophylaxe Pflegestandard (21.12.2022)

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)

Regulated handling of custodial measures

Standard Fixierungen und Alternativen (03.05.2021)

Regulated handling of occurring malfunctions of devices

Dienstanweisung zu MPG und MPBetreibV (Medizintechnik) (30.03.2022)

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

• Qualitätszirkel
• Tumorkonferenzen
• Mortalitäts- und Morbiditätskonferenzen
• Palliativbesprechungen
• Leitungszirkel
• Perinatalkonferenzen

Use of standardised information sheets

Application of standardised surgical check lists

Preoperative summary of predictable critical surgical steps, surgical time and expected blood loss

OP-Checkliste (31.05.2022)

Preoperative, complete presentation of necessary findings

Voruntersuchungen zur Narkose (15.07.2021)

Procedure to avoid procedural and patient mix-ups

Verfahrensanweisung Patientenidentifikationsarmbänder (22.11.2021)

Standards for recovery and postoperative care

Standard zur postoperativen pflegerischen Versorgung des Patienten (12.08.2020)

Discharge management

Verfahrensanweisung Entlassmanagement (07.10.2022)

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

As of: 02.08.2021

Internal evaluation of the received reports

taken jährlich

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

taken monatlich

Other

CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association, National Association of Statutory Health Insurance Doctors)

KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors)