Dealing with risks in patient care
Quality management
Prof. Dr. med. Völker Fendrich
Qualitätsmanagement-Beauftragter Arzt
Dehnhaide 120
22081 Hamburg
Phone:
040
-2092-7101
Mail:
ed.kinilk-neohcs@hcirdnefv
Klinikleitung, Vertreter der Pflege, Vertreter der Ärzteschaft, Qualitätsmanagement, Technik, Service, Therapie, IT
Conference frequency: bei Bedarf
Risk management
Patrycja Godlewska
Junior Qualitätsmanagerin
Phone:
040
-2092-1039
Fax: 040-2092-3709
Mail:
ed.kinilk-neohcs@aksweldogp
Risikomanagement, Qualitätsmanagement, Bereichsleitung Pflege/ QM, Qualitätsbauftragter Arzt
Conference frequency: bei Bedarf
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qulitätsagenda (08.02.2021) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Qulitätsagenda (08.02.2021) |
| RM05 |
Pain management Qulitätsagenda (08.02.2021) |
| RM06 |
Fall prophylaxis Qulitätsagenda (08.02.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Qulitätsagenda (08.02.2021) |
| RM08 |
Regulated handling of custodial measures Qulitätsagenda (08.02.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices Qulitätsagenda (08.02.2021) |
| 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 Qulitätsagenda (08.02.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings Qulitätsagenda (08.02.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Qulitätsagenda (08.02.2021) |
| RM17 |
Standards for recovery and postoperative care Qulitätsagenda (08.02.2021) |
| RM18 |
Discharge management Qulitätsagenda (08.02.2021) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Arzneimitteltherapiesicherheit (AMTS) - Schön Klinik-Standard: AMTS bedeutet die sichere Anwendung von Arzneimitteln. Dabei wird eine optimale Organisation des Medikationsprozesses angestrebt mit dem Ziel, auf Medikationsfehlern beruhende unerwünschte Ereignisse zu vermeiden und somit Risiken in der Therapie zu minimieren. Dieser Standard orientiert sich inhaltlich stark an den Empfehlungen des Aktionsbündnis Patientensicherheit.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 28.09.2022 |
| 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: bei Bedarf
| No. | Explanation |
|---|---|
| EF02 |
CIRS Berlin (Medical Association Berlin, German Medical Association, National Association of Statutory Health Insurance Doctors) |