Dealing with risks in patient care
Quality management
Dr. Dirk Schaper
CA Medizinmanagement
Mauerstraße 5
06110 Halle (Saale)
Phone:
0345
-213-4010
Mail:
ed.elaas-ellah-suahneknark@repahcs.d
QM-Projektgruppe: Medizinmanagement, Fachkraft für Arbeitssicherheit, Mitarbeitervertretung, Direktorium wird b.B. hinzugezogen
Conference frequency: monatlich
Risk management
Dirk Schaper
CA Medizinmanagement
06003 Halle (Saale)
Phone:
0345
-213-4010
Fax: 0345-213-4012
Mail:
ed.elaas-ellah-suahneknark@repahcs.d
Steuerungsgruppe "Patientensicherheit": Klinische Risikomanager aus dem Bereich Medizinmanagement, Vertreter*innen aus Pflege und Ärzteschaft; Direktorium als Entscheidungsinstanz (sowie Arbeitsgruppe "Umfassendes Risikomanagement" mit Vertreter*innen der Kaufmänn. Abt. m. quartalsweisen Treffen)
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Zentrale Dokumentenlenkung über "roXtra" (22.09.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management DA "Innerbetriebliches Notfallmanagement" (08.04.2022) |
| RM05 |
Pain management Dienstanweisung "Schmerzmessung in der Pflege" (01.10.2012) |
| RM06 |
Fall prophylaxis Dienstanweisung "Sturzprophylaxe" (22.06.2020) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dienstanweisung "Dekubitus-Prophylaxe und Therapie" (23.03.2020) |
| RM08 |
Regulated handling of custodial measures Dienstanweisung "Umgang mit der Fixierung von Patienten" (08.10.2009) |
| RM09 |
Regulated handling of occurring malfunctions of devices Dienstanweisung "Umgang mit Medizinprodukten/Anwenderpflichten" (05.07.2022) |
| 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 Dienstanweisung "Sicherheitscheckliste Operation/Invasive Eingriffe/Untersuchungen" (01.04.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings Dienstanweisung "Sicherheitscheckliste Operation/Invasive Eingriffe/Untersuchungen" (01.04.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Dienstanweisung "Sicherheitscheckliste Operation/Invasive Eingriffe/Untersuchungen" (01.04.2021) |
| RM17 |
Standards for recovery and postoperative care Dienstanweisung "Überwachungsstandard Aufwachraum" (08.09.2022) |
| RM18 |
Discharge management Beschreibung der Organisation "Standardisiertes Entlassmanagement" (12.12.2022) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Sensibilisierung der MA in Teambesprechungen, Anpassung Abläufe, Notruftaste an MA-DECT-Telefon, Anpassungen in Elektronischer Patientenakte (Anwendung und Schnittstellen), Schulung, Anpassung Dokumente
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 14.06.2023 |
| IF02 |
Internal evaluation of the received reports taken monatlich |
| 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: monatlich
| No. | Explanation |
|---|---|
|
Other |
|
| EF03 |
KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors) |