Dealing with risks in patient care
Quality management
Dipl.-Kffr. (FH) Birgit Stühmeier
QMB, Assistentin des Verwaltungsdirektors
Bavariaring 46
80336 München
Phone:
089
-1304-2215
Mail:
ed.noitkeridsuahneknark@reiemheuts.tigrib
Oberarzt Chirurgie- Zentrumsleiter, -Koordinator, QMB und Verwaltungsdirektor
Conference frequency: quartalsweise
Risk management
Birgit Stühmeier
QMB, Assistentin des Verwaltungsdirektors
Phone:
089
-1304-2215
Mail:
ed.noitkeridsuahneknark@reiemheuts.tigrib
Krankenhausleitung
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitätsmanagementhandbuch (01.06.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Medizinischer Notfall /VA_72) Stand 3/2023 Herzalarm (SOP_65) Stand 12/2022 Notfallplan (SOP_81) Stand 12/2022 Frühwarnsystem Sepsis (SOP_99) Stand 06/2022 (01.03.2023) |
| RM05 |
Pain management Postoperative Schmerztherapie (SOP_73) (01.06.2023) |
| RM06 |
Fall prophylaxis Sturzprophylaxe (ST_12) Stand 10/2020 Sturzereignis (ST_11) Stand 04/2023 Patienteninfo zur Sturzprophylaxe (IN_6) Stand 10/2021 (01.04.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusprophylaxe Expertenstandard ST_9 (01.02.2020) |
| RM08 |
Regulated handling of custodial measures Freiheitsentziehende Maßnahmen (FEM) ST_57 Stand 6/2021 Dokumentation FEM FO_194 Stand 2/2023 (03.01.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Organisationshandbuch Medizintechnik Stand 08/2012; Umgang mit defekten Geräten VA_88 Stand 06/2023 (01.06.2023) |
| 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 Dienstanweisungen zum Transfusionswesen; Patient Blood Management (PBM) (01.01.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings Qualitätszirkel LF_21 Stand 05/2021 Tumorkonferenz LF_20 Stand 05/2022 Röntgenkoferenz LF_24 Stand 05/2021 (01.05.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Sicherheitscheckliste nach WHO (01.05.2019) |
| RM17 |
Standards for recovery and postoperative care Überwachung im Aufwachraum ST_92 Stand 06/2023 (01.06.2023) |
| RM18 |
Discharge management Entlassmanagement-Entlassplan (FO_129) Stand 01/2020 Entlassung in amb/stat. Pflegeeinrichtung (VA_95) Stand 05/2021 Entlassung in AHB (VA_96) Stand 05/2021 (01.05.2021) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Verbesserung von Prozessen im Krankenhaus, Anpassung / Optimierung von Prozessen, Schulungen für Personal, technische Änderungen wie z.B. Schnittstellen zwischen EDV-Systemen geschaffen
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.10.2022 |
| IF02 |
Internal evaluation of the received reports taken bei Bedarf |
| 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: