Dealing with risks in patient care
Quality management
Manja Mohr
Standortübergreifende Leitung Qualitäts-, Risiko- & Prozessmanagement
Seilerweg 29
36251 Bad Hersfeld
Phone:
06623
-88-6221
Mail:
ed.feh-mukinilk@tnemeganamsteatilauq
Geschäftsführung / Ärztlicher Dienst / Pflegedienst / Verwaltung
Conference frequency: quartalsweise
Risk management
Manja Mohr
Standortübergreifende Leitung Qualitäts-, Risiko- & Prozessmanagement
Phone:
06623
-88-6221
Fax: 06623-88-6262
Mail:
ed.feh-mukinilk@tnemeganamsteatilauq
Lenkungskreis Klinisches Risikomanagement: ÄD, Pflegedienst, Risikomanager, QM, Therapie, Betriebsrat, IFG, MVZ
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikopolitik (08.11.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Risikopolitik (08.11.2023) |
| RM05 |
Pain management Risikopolitik (08.11.2023) |
| RM06 |
Fall prophylaxis Risikopolitik (08.11.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Risikopolitik (08.11.2023) |
| RM08 |
Regulated handling of custodial measures Risikopolitik (08.11.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Risikopolitik (08.11.2023) |
| 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,OP-Dokumentation (01.01.2016) |
| RM15 |
Preoperative, complete presentation of necessary findings Checkliste OP,Team-Time-Out-Regelung (01.01.2016) |
| RM16 |
Procedure to avoid procedural and patient mix-ups OP-Checkliste,Team-Time-Out,Patientenidentifikationsarmbänder (29.03.2022) |
| RM17 |
Standards for recovery and postoperative care Risikopolitik (08.11.2023) |
| RM18 |
Discharge management Risikopolitik (08.11.2023) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Mitarbeiterschulung im Umgang mit Laborproben, Warnwesten für medikamentenstellendes Pflegefachpersonal
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 19.01.2023 |
| 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 halbjährlich |
Conference committee
Conference frequency: quartalsweise
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |