Krankenhaus Martha-Maria Nürnberg

Comprehensive quality and/or risk management documentation (QM/RM documentation) is available

QM-/RM-Dokumentenmanagementsystem (EDV-gestützt); u.a. VA Dokumentierte Information; Rahmenkonzept Risikomanagement; Risikomanagement-Handbuch des Krankenhauses; Risikoerfassungsbogen (04.11.2022)

Regular further education and training measures

Employee surveys

Clinical emergency management

u.a. VA Ablauf Reanimation/Notfall Stationen (31.10.2022)

Pain management

u.a. Schmerzmanagement/Chirurgie; Leitlinie Schmerztherapie/Orthopädie; Expertenstandard in der Pflege; VA Schmerztherapie (11.10.2022)

Fall prophylaxis

u.a. Expertenstandard Sturzprophylaxe in der Pflege (07.01.2021)

Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”)

u.a. VA Umsetzung des nationalen Expertenstandards Dekubitusprophylaxe, Expertenstandard Dekubitusprophylaxe in der Pflege (01.12.2022)

Regulated handling of custodial measures

u.a. VA Unterbringungsähnliche Maßnahmen, Formular Verlaufsdokumentation zu unterbringsähnlichen Maßnahmen (04.12.2020)

Regulated handling of occurring malfunctions of devices

Organisationshandbuch Medizintechnik (04.08.2022)

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

• Qualitätszirkel
• Tumorkonferenzen
• Mortalitäts- und Morbiditätskonferenzen
• Pathologiebesprechungen
• Palliativbesprechungen
• CIRS-Fallbesprechungen

Use of standardised information sheets

Application of standardised surgical check lists

Preoperative summary of predictable critical surgical steps, surgical time and expected blood loss

u.a. Team Time-out; WHO-Sicherheitscheckliste (21.10.2019)

Preoperative, complete presentation of necessary findings

u.a. WHO-Sicherheitscheckliste (21.10.2019)

Procedure to avoid procedural and patient mix-ups

u.a. Team Time-out; WHO-Sicherheitscheckliste; Einwilligung Patientenarmband (03.05.2021)

Standards for recovery and postoperative care

u.a. VA Schmerztherapie im Aufwachraum (01.12.2022)

Discharge management

u.a. VA Entlassungsprozess bei stationärer und ambulanter Pflege, Entlassmanagement (05.02.2021)

Documentation and procedural instructions for handling the error reporting system are available

As of: 30.11.2022

Internal evaluation of the received reports

taken bei Bedarf

Training of employees in handling the error reporting system and in implementing the findings from the error reporting system

taken bei Bedarf

KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors)