Dealing with risks in patient care

Quality management

Frau Bernadette Schäfer

Leitung Qualitäts- und Projektmanagement

Diakonissenstraße 28
76199 Karlsruhe

Phone: 0721 -8108-8008
Mail: ed.ak-suitnecniv@refeahcs.ettedanreb

Conference frequency:

Risk management

Maik Beltrame

Prokurist / Leitung Allgemeine Verwaltung

Diakonissenstraße 28
76199 Karlsruhe

Phone: 0721 -8108-2036
Fax: 0721-8108-2100
Mail: ed.ak-kaid@emartleb.m

Conference frequency:

Risk management instruments and measures

No. Explanation
RM01

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

Qualitätsmanagement, Risikomanagement (30.09.2019)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Notfalleinsatzprotokoll (03.01.2021)

RM05

Pain management

Umgang mit akutem Schmerz (22.11.2019)

RM06

Fall prophylaxis

Sturzprophylaxe (19.01.2021)

RM07

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

Dekubitusprophylaxe (05.09.2022)

RM08

Regulated handling of custodial measures

Name: Freiheitsentziehende Maßnahmen (17.10.2018)

RM09

Regulated handling of occurring malfunctions of devices

Organisationshandbuch Medizintechnik (01.01.2017)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Qualitätszirkel
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 (02.10.2019)

RM15

Preoperative, complete presentation of necessary findings

Fachabteilungsspezifische Standards (31.12.2016)

RM16

Procedure to avoid procedural and patient mix-ups

Checklisten Team Time Out (30.04.2016)

RM17

Standards for recovery and postoperative care

Verfahrensanweisung Aufwachraum (23.02.2017)

RM18

Discharge management

Entlassmanagement (02.10.2019)

Fault reporting systems

Conference committee

Conference frequency: bei Bedarf

Measures

CIRS ist ein anonymes Berichtsystem zur Meldung, Erfassung und Auswertung von kritischen Ereignissen. Ziel ist die Ableitung und Umsetzung von praxisbezogenen und risikopräventiven Maßnahmen. Analyse von kritischen Zwischenmeldungen zur Verbesserung der Patientensicherheit und Fehler- und Schadensvermeidung.Antibiotic-Stewardship. Ethik-Komitee. CIRS u.v.m.

No. Explanation
IF01

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

As of: 16.03.2021

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 halbjährlich

Conference committee

Conference frequency: bei Bedarf

No. Explanation
EF15

PaSIS (Patient Safety and Information System of the University Hospital Tübingen)