Dealing with risks in patient care

Quality management

Alexandra Budde

Leitung Qualitätsmanagement; Klinisches Risikomanagement

Süntelstraße 11a
22457 Hamburg

Phone: 040 -5588-4035
Mail: ed.nenitreblaleunammi@eddub.ardnaxela

Direktorium (GF, ÄD, PD), QM

Conference frequency: quartalsweise

Risk management

Alexandra Budde

Leitung Qualitätsmanagement; Klinisches Risikomanagement

Phone: 040 -5588-4035
Mail: ed.nenitreblaleunammi@eddub.ardnaxela

Direktorium (GF, ÄD, PD), QM

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

QM-/RM-Dokumentation (04.12.2023)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

VA Innerklinisches Notfallmanagement (23.02.2023)

RM05

Pain management

Schmerzmanagement im AKH/AH (27.11.2023)

RM06

Fall prophylaxis

VA Sturzprophylaxe Pflege (01.12.2023)

RM07

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

VA Dekubitusprophylaxe (05.01.2024)

RM08

Regulated handling of custodial measures

Teil der QM/RM-Dokumentation (gemäß RM01) (19.08.2024)

RM09

Regulated handling of occurring malfunctions of devices

MT VA Störmeldung (19.08.2024)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Palliativbesprechungen
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 Anwendung OP-Sicherheitscheckliste (01.12.2023)

RM15

Preoperative, complete presentation of necessary findings

VA Anwendung OP-Sicherheitscheckliste (01.12.2023)

RM16

Procedure to avoid procedural and patient mix-ups

Vermeidung einer Eingriffsverwechslung (22.05.2024)

RM17

Standards for recovery and postoperative care

VA Anwendung OP-Sicherheitscheckliste (01.12.2023)

RM18

Discharge management

Entlassmanagement (23.06.2023)

Fault reporting systems

Conference committee

Conference frequency: quartalsweise

Measures

Maßnahmen zur sicheren Patientenidentifikation; Optimierung innerklinischer Prozesse; Anpassung OP-Sicherheitscheckliste; Durchführung von Risikoanalysen

No. Explanation
IF01

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

As of: 19.08.2024

IF02

Internal evaluation of the received reports

taken quartalsweise

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: quartalsweise

No. Explanation

Other