Dr.med. Pascal Scher, Christa Gottwald, Dr. med. Christian Unzicker (bis 3/23), Dr. med. Andreas Schöne (5/23 - 10/23) Dr. Lydia Hekeler (ab 11/23), Astrid Göttlicher, Rosa-Maria Stahl (ab 3/23), Dr. med. Tim-Oliver Guderjahn (bis 1/23)

Klinikleitung

Englschalkinger Str. 77
81925 München

Phone: 089 -9270-2001
Fax: 089-9270-2014
Mail: ed.kinilk-nehcneum@bk.gnutielkinilk.tairaterkes

Steering committee

alle klinischen Bereiche

Conference frequency: jährlich

Risk management instruments and measures

Instruments and measures

No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Zentrales elektronisches Organisationshandbuch und zusätzlich Datenbank zum Risikomeldesystem (01.01.2020)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Prioritätenorientiertes Schockraummanagement (01.03.2019)
RM05	Pain management VA Expertenstandard Schmerzmanagement in der Pflege (30.05.2022)
RM06	Fall prophylaxis EDV-Tool, Expertenstandard Sturzprophylaxe in der Pflege (01.05.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) EDV-Tool, Expertenstandard Dekubitusprophylaxe in der Pflege (01.05.2022)
RM08	Regulated handling of custodial measures DA Anwendung von freiheitsentziehenden Maßnahmen (01.10.2019)
RM09	Regulated handling of occurring malfunctions of devices DA Errichten, Betreiben und Instandhalten von Medizinprodukten (01.08.2018)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Pathologiebesprechungen Palliativbesprechungen
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 Sicherheitscheckliste (16.02.2023)
RM15	Preoperative, complete presentation of necessary findings Sicherheitscheckliste (16.02.2023)
RM16	Procedure to avoid procedural and patient mix-ups DA Vermeidung von Seiten- und Eingriffsverwechslung (15.07.2021)
RM17	Standards for recovery and postoperative care VA Entlassmanagement (01.09.2023)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: bei Bedarf

Measures

• Sensibilisierung für mögliche Verwechslungsrisiken bei ähnlich aussehenden Medikamentenverpackungen und ähnlich klingenden Medikamentennamen • Herstellerwechsel, wenn sinnvoll und notwendig • Durchführung von Geräteeinweisungen und Materialschulungen • Verbesserung der Materialbezeichnungen in der Bestellliste • Nutzung von Hinweisen zur Erstellung StKM-einheitlicher Regelungen • Einführung der OP-Sicherheits-Checkliste als Anlage zum OP-Statut

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 01.08.2014
IF02	Internal evaluation of the received reports taken halbjährlich
IF03	Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken bei Bedarf

No.

Explanation

IF01

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

As of: 01.08.2014

IF02

Internal evaluation of the received reports

taken halbjährlich

IF03

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

taken bei Bedarf

Across all institutions

Conference committee

Conference frequency: bei Bedarf

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)