Dealing with risks in patient care
Quality management
Dr. Ulrich Rosien
Kommissarischer Chefarzt der Medizinischen Klinik; Leiter Endoskopie;
Orchideenstieg 14
22297 Hamburg
Phone:
040
-51125-5010
Mail:
ed.h-ki@neisor.u
gesamtes Krankenhaus
Conference frequency: quartalsweise
Risk management
Ulrich Rosien
Kommissarischer Chefarzt der Medizinischen Klinik; Leiter Endoskopie;
Phone:
040
-51125-5010
Fax: 040-51125-5011
Mail:
ed.h-ki@neisor.u
Medizinische Klinik; Chirurgische Klinik; Anästhesie; Pflegedienst; Verwaltung
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QMH (01.04.2021) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Diverse Notfalldokumente (Checklisten, Formulare) (01.04.2021) |
| RM05 |
Pain management Leitfaden:Empfehlung zur SchmerztherapieAutor: PD Dr. M. Freitag; Dr. J-H Stork (01.04.2021) |
| RM06 |
Fall prophylaxis Pflegestandard Sturzprophylaxe (basierend auf dem Expertenstandard Sturzprophylaxe) (29.04.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Pflegestandard Dekubitusprophylaxe (basierend auf dem Expertenstandard Dekubitusprophylaxe) (01.06.2021) |
| RM08 |
Regulated handling of custodial measures Verfahrensanweisung Umgang mit freiheitsentziehenden Maßnahmen (01.04.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices Reparaturformular Medizintechnik (01.04.2021) |
| 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 QMH (01.04.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings QMH (01.04.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups VA Maßnahmen zur Vermeidung von Patientenverwechselungen, VA Patientenidentifikation Endoskopie, Workflow Sichere Patientenidentifikation in der Aufnahme, VA Patientenidentität OP/Anästhesie (27.01.2021) |
| RM17 |
Standards for recovery and postoperative care SOP postoperative Überwachung auf den Normalstationen (25.04.2021) |
| RM18 |
Discharge management Verfahrensanweisung Sozial und EntlassmanagementSOP Entlassungsmanagement in der Pflege (12.01.2021) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
CIRS; Fehlermeldeformulare; Risikochecklisten sowie definierter Prozess zur Patientensicherheit.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.10.2021 |
| 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 monatlich |
Conference committee
Conference frequency: jährlich
| No. | Explanation |
|---|---|
|
Other |
|
|
Other |
|
| EF01 |
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) |