Dealing with risks in patient care
Quality management
Martina Stangl
QMB, RM
Westtor 7
48324 Sendenhorst
Phone:
02526
-300-1157
Mail:
ed.tfits-fesoj-ts@lgnats
- Forumssitzung (Geschäftsführung, Krankenhausbetriebsleitung, Chefärzte der einzelnen Fachabteilungen) - Tagung: monatlich - Montagsrunde (Geschäftsführung, Krankenhausbetriebsleitung, Leitung Hauswirtschaft, Technik, Personal, Öffentlichkeitsarbeit) - Tagung: wöchentlich
Conference frequency: andere Frequenz
Risk management
Martina Stangl
QMB, RM
48318 Sendenhorst
Phone:
02526
-300-1157
Fax: 02526-300-1159
Mail:
ed.tfits-fesoj-ts@lgnats
- Forumssitzung (Geschäftsführung, Krankenhausbetriebsleitung, Chefärzte der einzelnen Fachabteilungen) - Tagung: monatlich - Montagsrunde (Geschäftsführung, Krankenhausbetriebsleitung, Leitung Hauswirtschaft, Technik, Personal, Öffentlichkeitsarbeit) - Tagung: wöchentlich
Conference frequency: andere Frequenz
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM-Handbuch (03.05.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management QM-Handbuch (03.05.2023) |
| RM05 |
Pain management QM-Handbuch (03.05.2023) |
| RM06 |
Fall prophylaxis QM-Handbuch (03.05.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) QM-Handbuch (03.05.2023) |
| RM08 |
Regulated handling of custodial measures QM-Handbuch (03.05.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices QM-Handbuch (03.05.2023) |
| 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 QM-Handbuch (03.05.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings QM-Handbuch (03.05.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups QM-Handbuch (03.05.2023) |
| RM17 |
Standards for recovery and postoperative care QM-Handbuch (03.05.2023) |
| RM18 |
Discharge management QM-Handbuch (03.05.2023) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
- Erhöhung der Meldefrequenz - Verbesserung der Umsetzung von Meldungen - Konkrete Vorbereitung und Entscheidung zum Einsatz eines einrichtungsübergreifenden Fehlermeldesystems
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 18.08.2022 |
| 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 jährlich |
Conference committee
Conference frequency: