Dealing with risks in patient care
Quality management
Anja Bertelmann-Gschlößl
Krankenschwester/Palliativmedizin, Qualitätsberaterin/Qualitätsmanagement des Klinikums
Alois-Steinecker-Straße 18
85354 Freising
Phone:
08161
-24-4105
Mail:
ed.gnisierf-mukinilk@nnamletreb
Dr. Andrea Stege
Qualitätsmanagerin / Riskomanagerin des Klinikums
Alois-Steinecker-Straße 18
85354 Freising
Phone:
08161
-24-3207
Mail:
ed.gnisierf-mukinilk@MQ
Qualitätsmanagementbeauftragte Personen: Dr. Andrea Stege, zentrales QM Karin Schinnerl, QM Verwaltung Anja Bertelmann-Gschlößl, QM Pflege Dr. med. Timo Schmidt-Hönsdorf, ärztlicher Dienst Chirurgie Dr. med. Markus Ziegltrum, ärztlicher Dienst Innere Medizin
Conference frequency: monatlich
Risk management
Frank Bernutz
Abteilungsleitung Einkauf/Qualitätsmanagementbeauftragter Verwaltung
Phone:
08161
-24-3100
Mail:
ed.gnisierf-mukinilk@fztunreb
Andrea Stege
Qualitätsmanagerin / Riskomanagerin des Klinikums
Phone:
08161
-24-3207
Mail:
ed.gnisierf-mukinilk@MQ
Conference frequency:
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Dr. A. Stege (05.09.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Dr. A. Stege (05.09.2023) |
| RM05 |
Pain management Dr. A. Stege (05.09.2023) |
| RM06 |
Fall prophylaxis Dr. A. Stege (05.09.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) A. Bertelman-Gschlößl (05.09.2023) |
| RM08 |
Regulated handling of custodial measures Dr. A. Stege (05.09.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Dr. A. Stege (05.09.2023) |
| 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 Dr. A. Stege (05.09.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings Dr. A. Stege (05.09.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Dr. A. Stege (05.09.2023) |
| RM17 |
Standards for recovery and postoperative care Dr. A. Stege (05.09.2023) |
| RM18 |
Discharge management Dr. A. Stege (05.09.2023) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Patientenidentifikationsbänder Team-Time-Out im OP Vorbereitungschecklisten OP und Endoskopie Zählkontrollen des benutzten Materials während Operationen technische Überprüfungen der Versorgungsanlagen und medizinischen Geräte multiprofessionelles Expertenteam im Bereich der Hygiene Sturzprophylaxe im Rahmen des Expertenstandards Arzneimittelsicherheit CIRS
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 05.09.2023 |
| IF02 |
Internal evaluation of the received reports taken jährlich |
| 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: