Dealing with risks in patient care
Quality management
Anna Daria Leja
Leitung Qualitätsmanagement
Groß-Sand 3
21107 Hamburg
Phone:
040
-75205-232
Mail:
ed.dnas-ssorg@ajel.a
Chefärzte Zentrum für Geriatrie und Frührehabilitation, Pflegedirektorin, Abteilungsleitungen Pflege Geriatrie und NNF, Qualitätsmanagementbeauftragte, Qualitätsbeauftragte Pflege, Gesamtleitung Therapie
Conference frequency: monatlich
Risk management
Qualitätsmanagement&Klinisches Risikomanagement, Pflegedienst, Ärztlicher Dienst, Sozialdienst, Physiotherapie
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikomanagement-Konzept (14.02.2019) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management VA Innerklinisches Notfallmanagement (29.09.2022) |
| RM05 |
Pain management VA zum Expertenstandard "Schmerztherapie bei akuten Schmerzen" (04.11.2022) |
| RM06 |
Fall prophylaxis VA zur Umsetzung der Leitlinie Sturzprophylaxe in der Pflege (10.02.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) VA zur Umsetzung der Leitlinie Dekubitusprophylaxe in der Pflege (06.12.2022) |
| RM08 |
Regulated handling of custodial measures Umgang mit freiheitsentziehenden Maßnahmen (12.01.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices VA Zwischenfallmeldungen (05.12.2018) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM13 |
Application of standardised surgical check lists |
| RM14 |
Preoperative summary of predictable critical surgical steps, surgical time and expected blood loss WHO-Sicherheitscheckliste OP (17.12.2019) |
| RM15 |
Preoperative, complete presentation of necessary findings WHO-Sicherhetscheckliste OP (17.12.2019) |
| RM16 |
Procedure to avoid procedural and patient mix-ups WHO-Sicherheitscheckliste OP (17.12.2019) |
| RM17 |
Standards for recovery and postoperative care VA Postoperative Patientenüberwachung Aufwachraum (17.12.2019) |
| RM18 |
Discharge management Umsetzung des Entlassmanagements (28.07.2020) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Ein CIRS ist eingerichtet, Meldungen können über das Intranet, auch anonym, erfolgen.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 05.12.2018 |
| 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 jährlich |
Conference committee
Conference frequency: bei Bedarf
| No. | Explanation |
|---|---|
|
Other |