Dealing with risks in patient care
Quality management
Diana Mengel
Qualitätsmanagementbeauftragte
Calandstr. 7/8
18528 Bergen auf Rügen
Phone:
03838
-39-1080
Mail:
ed.anas@legnem.anaid
Geschäftsführung, Prokuristin/ Leiterin UB Allgemeine Verwaltung und Personal, Ärztlicher Direktor, Pflegedirektion, Leitung UB Controlling/ Finanzen, Betriebsrat, Qualitätsmanagementbeauftragte
Conference frequency: quartalsweise
Risk management
Diana Mengel
Qualitätsmanagementbeauftragte
Calandstr. 7/8
18528 Bergen auf Rügen
Phone:
03838
-39-1080
Mail:
ed.anas@legnem.anaid
Geschäftsführung, Prokuristin/ Leiterin UB Allgemeine Verwaltung und Personal, Ärztlicher Direktor, Pflegedirektion, Leitung UB Controlling/ Finanzen, Betriebsrat, Qualitätsmanagementbeauftragte
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Sana Management Handbuch (SMH) (10.10.2023) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Sana Management Handbuch (SMH) (17.11.2022) |
| RM05 |
Pain management Sana Management Handbuch (SMH) (26.10.2021) |
| RM06 |
Fall prophylaxis Sana Management Handbuch (SMH) (29.09.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Sana Management Handbuch (SMH) (17.11.2022) |
| RM08 |
Regulated handling of custodial measures Sana Management Handbuch (SMH) (13.11.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Sana Management Handbuch (SMH) (26.10.2021) |
| 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 Sana Management Handbuch (SMH) (26.10.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings Sana Management Handbuch (SMH) (07.11.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Sana Management Handbuch (SMH) (26.10.2021) |
| RM17 |
Standards for recovery and postoperative care Sana Management Handbuch (SMH) (19.12.2022) |
| RM18 |
Discharge management Sana Management Handbuch (SMH) (24.03.2023) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Werktägliche Sichtung eingegangener kritischer Ereignisse, Information über kritische Ereignisse an die Verantwortlichen, Anpassung von Prozessabläufen und Strukturen, Aufnahme von kritischen Aspekten in die interne Auditplanung zur regelmäßigen Überprüfung, Zusammenarbeit mit dem Konzern bei speziellen Fragestellungen, regelhafte Publikation kritischer Ereignisse/ eingeleiteter Verbesserungsmaßnahmen, Sichtung und interne Publikation kritischer Ereignisse aus anderen Kliniken/ Krankenhäusern
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.07.2020 |
| IF02 |
Internal evaluation of the received reports taken quartalsweise |
| 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: quartalsweise
| No. | Explanation |
|---|---|
|
Other |