Dealing with risks in patient care
Quality management
Gregor Mack
Qualitätsmanagementbeauftragter
Vinzenz-von-Paul-Str. 10
84503 Altötting
Phone:
08671
-509-1330
Mail:
ed.mukinilknni@kcam.g
Vertreter aller Berufsgruppen und Fachbereiche der Klinik
Conference frequency: quartalsweise
Risk management
Ludwig Gutermuth
Leiter Risiko- und Prozessmanagement
Phone:
08671
-509-2777
Fax: 08671-509-1454
Mail:
ed.mukinilknni@htumretug.l
Vorstandsvorsitzender, Kaufmännischer Vorstand, Medizinvorstand Mühldorf/Haag, Medizinvorstand Altötting/Burghausen, Standortleitung/Verwaltungsleitung, Pflegedirektion, Risikomanager, QMB, verantwortlicher Leiter der zuständigen Berufsgruppe (Risikoexperte)
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Übergreifendes QM-Handbuch (24.03.2015) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Übergreifendes QM-Handbuch (24.03.2015) |
| RM05 |
Pain management Übergreifendes QM-Handbuch (24.03.2015) |
| RM06 |
Fall prophylaxis Expertenstandard Sturzprophylaxe in der Pflege (21.09.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitus (18.08.2022) |
| RM08 |
Regulated handling of custodial measures Übergreifendes QM-Handbuch (24.03.2015) |
| RM09 |
Regulated handling of occurring malfunctions of devices Übergreifendes QM-Handbuch (24.03.2015) |
| 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 Übergreifendes QM-Handbuch (24.03.2015) |
| RM15 |
Preoperative, complete presentation of necessary findings Übergreifendes QM-Handbuch (24.03.2015) |
| RM16 |
Procedure to avoid procedural and patient mix-ups OP-Statut der Kreiskliniken, Perioperative Checkliste (WHO) (19.05.2014) |
| RM17 |
Standards for recovery and postoperative care Übergreifendes QM-Handbuch (24.03.2015) |
| RM18 |
Discharge management Übergreifendes QM-Handbuch (24.03.2015) |
Fault reporting systems
Conference committee
Conference frequency: wöchentlich
Measures
Team Time out, M&M-Konferenzen in den Zentren, Medikamentensicherheit, IT-Sicherheit, Hygienemanagement, Umsetzung MPG, Triage bei Notfallaufnahmen
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 08.08.2023 |
| 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: wöchentlich
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors) |
| EF14 |
CIRS Health Care |