Dealing with risks in patient care
Quality management
Bärbel Knoche
Qualitätsmanagementbeauftragte
Kirchenweg 15
87459 Pfronten
Phone:
08363
-693-448
Mail:
ed.kinilk-znezniv@ehconk.lebreab
Qualitätsbeauftragte, Geschäftsführung, Chefärzte der Fachabteilungen
Conference frequency: bei Bedarf
Risk management
Bärbel Knoche
Risikomanagerin
Kirchenweg 15
87459 Pfronten
Phone:
08363
-693-448
Mail:
ed.kinilk-znezniv@ehconk.lebreab
QMB, HfK
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikomanagement-Handbuch (12.04.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Notfallmanagement (27.10.2023) |
| RM05 |
Pain management Schmerzstandard (12.05.2020) |
| RM06 |
Fall prophylaxis Ausgabe - Informationsbroschüre Vermeidung von Stürzen (04.04.2017) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusstandard (09.03.2023) |
| RM08 |
Regulated handling of custodial measures Standard Freiheitsentziehende Maßnahmen (30.05.2016) |
| RM09 |
Regulated handling of occurring malfunctions of devices Umsetzung MP-Recht im Bereich Medizintechnik (15.05.2018) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM13 |
Application of standardised surgical check lists |
| RM16 |
Procedure to avoid procedural and patient mix-ups OP-Sicherheitschecklisten (WHO orientiert) - seit 08.10.13 (23.07.2020) |
| RM17 |
Standards for recovery and postoperative care OP-Statut (22.09.2023) |
| RM18 |
Discharge management Entlassmanagement (13.09.2019) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Fehlermeldungen werden dem Gremium über das CIRS gemeldet, entsprechend bearbeitet, Maßnahmen werden festgelegt (ggf. in Rücksprache mit Geschäftsleitung) und entsprechend eingeleitet. Nach Beseitigung Eintrag in Auswertungsliste und Veröffentlichung der Auswertung (intern und anonymisiert). Durchführung des Risikomanagements (u.a.CIRS).
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 19.10.2023 |
| 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 monatlich |
Conference committee
Conference frequency: monatlich
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors) |