Dealing with risks in patient care

Quality management

Petra Pahl

QM-Beauftragte

Norderstr. 81
25980 Sylt/OT Westerland

Phone: 04651 -841101-
Mail: moc.soipelksa@lhap.p

Ärztlicher Direktor, Geschäftsführung, Pflegeleitung, Qualitäsmanagement, Betriebsrat, Controlling, Personalabteilung

Conference frequency: quartalsweise

Risk management

Petra Pahl

QM-Beauftragte

Norderstr. 81
25980 Sylt/OT Westerland

Phone: 04651 -841101-
Mail: moc.soipelksa@lhap.p

Ärztlicher Direktor, Geschäftsführung, Pflegeleitung, Qualitäsmanagement, Betriebsrat, Controlling, Personalabteilung

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

Konzept Klinisches Risikomanagement (30.05.2022)

RM02

Regular further education and training measures

RM04

Clinical emergency management

QM-Handbuch Notfallmanagement (03.12.2021)

RM05

Pain management

QM-Handbuch (23.03.2022)

RM06

Fall prophylaxis

QM-Handbuch (23.07.2019)

RM07

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

QM-Handbuch (28.06.2021)

RM08

Regulated handling of custodial measures

QM-Handbuch (13.10.2021)

RM09

Regulated handling of occurring malfunctions of devices

QM-Handbuch (05.07.2023)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Mortalitäts- und Morbiditätskonferenzen
  • Röntgenbesprechungen
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

QM-Handbuch (08.03.2023)

RM15

Preoperative, complete presentation of necessary findings

QM-Handbuch (08.03.2023)

RM16

Procedure to avoid procedural and patient mix-ups

QM-Handbuch (20.01.2022)

RM17

Standards for recovery and postoperative care

QM-Handbuch (23.03.2022)

RM18

Discharge management

QM-Handbuch (05.10.2021)

Fault reporting systems

Conference committee

Conference frequency: halbjährlich

Measures

Schulung und Sensibilisierung der Mitarbeiter zum Umgang mit Drei-Wege-Hahn SwabCabs an ZVK.

No. Explanation
IF01

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

As of: 10.06.2022

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: quartalsweise

No. Explanation

Other

EF14

CIRS Health Care