BG Klinikum Bergmannstrost Halle

Dealing with risks in patient care

Quality management

Jan Richter

Leiter Qualitäts- und Risikomanagement

Merseburger Straße 165
06112 Halle (Saale)

Phone: 0345-132-7569
Mail: ed.tsortsnnamgreb@rethcir.naj

Krankenhausleitung, Qualitäts- und Risikomanagement, Strategische Unternehmensentwicklung und Organisation

Conference frequency: quartalsweise

Risk management

Leiter Qualitäts- und Risikomanagement

Jan Richter

Merseburger Straße 165
06112 Halle (Saale)

Phone: 0345-132-7569
Fax: 0345-132-7570
Mail: ed.tsortsnnamgreb@rethcir.naj

Krankenhausleitung, Qualitäts- und Risikomanagement, Strategische Unternehmensentwicklung und Organisation

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

Organisation- und Managementhandbuch (IT-gestützt) (03.03.2021)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Organisation- und Managementhandbuch (IT-gestützt) (03.03.2021)

RM05

Pain management

Organisation- und Managementhandbuch (IT-gestützt) (03.03.2021)

RM06

Fall prophylaxis

Organisation- und Managementhandbuch (IT-gestützt) (03.03.2021)

RM07

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

Organisation- und Managementhandbuch (IT-gestützt) (03.03.2021)

RM08

Regulated handling of custodial measures

Organisation- und Managementhandbuch (IT-gestützt) (03.03.2021)

RM09

Regulated handling of occurring malfunctions of devices

Organisation- und Managementhandbuch (IT-gestützt) (03.03.2021)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Pathologiebesprechungen
  • Polytraumakonferenz
  • Komplikations- und Fallbesprechungen
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

Organisation- und Managementhandbuch (IT-gestützt) (03.03.2021)

RM15

Preoperative, complete presentation of necessary findings

Organisation- und Managementhandbuch (IT-gestützt) (03.03.2021)

RM16

Procedure to avoid procedural and patient mix-ups

Organisation- und Managementhandbuch (IT-gestützt) (03.03.2021)

RM17

Standards for recovery and postoperative care

Organisation- und Managementhandbuch (IT-gestützt) (03.03.2021)

RM18

Discharge management

Organisation- und Managementhandbuch (IT-gestützt) (03.03.2021)

Fault reporting systems

Conference committee

Conference frequency: quartalsweise

Measures

Beschaffung von zusätzlichem Equipment für Spezialfälle im Rahmen des medizinischen Notfallmanagements


No. Explanation
IF01

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

As of: 03.03.2021

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
EF03

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