Dealing with risks in patient care
Quality management
Dr. Mario Paulig
Leitender Oberarzt
Parzivalplatz 4
80804 München
Phone:
089
-36087-2733
Mail:
ed.kinilk-neohcs@giluapm
Qualitätskommission
Conference frequency: monatlich
Risk management
Andrea Sporn-Sooss
Qualitäts- und klinisches Risikomanagement
Phone:
089
-36087-1648
Mail:
ed.kinilk-neohcs@ssoosnropsa
Qualitätskommission, Hygienekommission, Arbeitssicherheitsausschuss, Arzneimittelkommission, Antibiotic Stewardship, Klinikleitungsbesprechung, Stationsreporting Risikoreview mit Beteiligung der Klinikleitung, Qualitätsmanagement und Risikomanagement (quartalsweise)
Conference frequency: andere Frequenz
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Zentrales Dokumentenlenkungssystem; enthält die einzelnen Verfahrensanweisungen (01.10.2021) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management s. RM01 (31.05.2023) |
| RM06 |
Fall prophylaxis s. RM01 (21.11.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) s. RM01 (20.11.2022) |
| RM08 |
Regulated handling of custodial measures s. RM01 (02.10.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices s. RM01 (24.01.2023) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM16 |
Procedure to avoid procedural and patient mix-ups s. RM01 (08.04.2022) |
| RM18 |
Discharge management s. RM01 (12.05.2023) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
- Patientenidentifikationsarmbänder - Standard Sturzrisikoassessment und Sturzprophylaxe - Standard Arzneimitteltherapiesicherheit/Leitlinie Arzneimitteltherapiesicherheit - CIRS - Checkliste "Selbstgefährdendes Verhalten und Suizidalität" - Standard "Demenz" - Checkliste "Demenz" - Basishygiene MSW - SK-Risikomanagement - Helmbedarf
| 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) |