Dealing with risks in patient care

Quality management

Jens Ritter

Geschäftsführer

Oskar-Alexander-Str. 26
24576 Bad Bramstedt

Phone: 04192 -902011-
Mail: ed.bbmukinilk@fg

Geschäftsführung, Ärztlicher Direktor, Qualitäts-und Risikomanagement

Conference frequency: quartalsweise

Risk management

Jens Ritter

Geschäftsführer

Phone: 04192 -902011-
Mail: ed.bbmukinilk@fg

Geschäftsführung, Ärztlicher Direktor, Controlling, Qualitäts-und Risikomanagement, Pflegedienstleitung, Ärztliche Leitungen der Fachabteilungen etc.

Conference frequency: halbjährlich

Risk management instruments and measures

No. Explanation
RM01

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

Risikokataster (09.11.2021)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Risikokataster (09.11.2021)

RM05

Pain management

Leitlinie Schmerzmanagement, Pflegestandard Schmerzmanagement (02.03.2020)

RM06

Fall prophylaxis

Leitlinie Sturzprophylaxe (02.03.2020)

RM07

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

Standard Dekubitusprophylaxe (17.10.2018)

RM08

Regulated handling of custodial measures

Verfahrensanweisung Fixierung (04.05.2021)

RM09

Regulated handling of occurring malfunctions of devices

Verfahren Vorkommnismeldung (11.04.2016)

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

Verfahren Patientensicherheit im OP (20.07.2020)

RM15

Preoperative, complete presentation of necessary findings

Verfahren Patientensicherheit im OP (20.07.2020)

RM16

Procedure to avoid procedural and patient mix-ups

Verfahren zur Patienteneinschleusung im OP, OP-Sicherheits-Checkliste (20.02.2019)

RM17

Standards for recovery and postoperative care

IMC Übergabe und Therapiebogen (20.05.2019)

RM18

Discharge management

Verfahren Entlassmanagement (18.03.2021)

Fault reporting systems

Conference committee

Conference frequency: quartalsweise

Measures

4-Augen-Prinzip, Patientenidentifikationsarmband im OP, Team-Time-Out, 5-R-Regel

No. Explanation
IF01

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

As of: 17.03.2021

IF02

Internal evaluation of the received reports

taken halbjährlich

IF03

Training of employees in handling the error reporting system and in implementing the findings from the error reporting system

taken bei Bedarf

Conference committee

Conference frequency: quartalsweise

No. Explanation

Other

Other