Dealing with risks in patient care
Quality management
Dr. Antje Schoppa
Leitung Abteilung für Organisationsentwicklung und Patientensicherheit
Prüfeninger Str. 86
93049 Regensburg
Phone:
0941
-369-1160
Mail:
ed.grubsneger-egizrehmrab@appohcs.ejtna
Geschäftsführung, Qualitätsmanagement, Pflegedirektion, Ärztlicher Dienst
Conference frequency: monatlich
Risk management
Elisabeth Lanzl
Teamleitung Projektmanagement und klinisches Risikomanagement Abteilung für Organisationsentwicklung und Patientensicherheit
93006 Regensburg
Phone:
0941
-369-1167
Fax: 0941-369-1185
Mail:
ed.grubsneger-egizrehmrab@lznal.htebasile
Patientensicherheitsteams (Pflegedienstleitung, Pflegedienst, Qualitätsmanagement, Ärztlicher Dienst)
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available BBR CIRS-Konzept; Risikomanagementkonzept Verbund (06.05.2025) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Verfahrensanweisung Medizinischer Notfall (16.04.2025) |
| RM05 |
Pain management Arbeitsanweisung Schmerzmanagement, Schmerzstandards, Schmerzkonzepte, Schmerzschemata jew. Fachabteilung (03.06.2025) |
| RM06 |
Fall prophylaxis Arbeitsanweisung Sturzprophylaxe (17.04.2025) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Pflegestandard PS 25.01 Dekubitusprophylaxe u.-therapie, Arbeitsanweisung Dekubitus (01.09.2025) |
| RM08 |
Regulated handling of custodial measures Fixierungsstandard (01.06.2025) |
| RM09 |
Regulated handling of occurring malfunctions of devices Verfahrensanweisung Umsetzung MPDG und MPBetreibV (04.09.2023) |
| 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 OP-Statut (12.08.2024) |
| RM15 |
Preoperative, complete presentation of necessary findings OP-Statut (12.08.2024) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Verfahrensanweisung Patientenidentifikation (13.08.2024) |
| RM17 |
Standards for recovery and postoperative care Pflegestandard postoperative Pflege PS23.01 Standard postoperativer Schmerz (15.03.2022) |
| RM18 |
Discharge management Verfahrensanweisung Entlassmanagement (17.03.2023) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Risikomanagement (CIRS), Beschwerdemanagement, Fehlermanagement, Interne und externe Audits Begehungen
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 15.09.2025 |
| 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 jährlich |
Conference committee
Conference frequency: monatlich
| No. | Explanation |
|---|---|
|
Other |
|
| EF01 |
CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association) |
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |