Dealing with risks in patient care
Quality management
Clemens Moll
Beauftragte für Risiko- und Qualitätsmanagement
Am Vogelherd 14
88239 Wangen
Phone:
07522
-797-1109
Mail:
ed.nekinilk-zw@llom.snemelc
Beteiligte der QM-Steuergruppe sind: jeweils ein ärztlicher und nichtärztlicher Vertreter aller Kliniken (Abteilungen) Krankenhausdirektor Hygienefachkraft Betriebsrat
Conference frequency: monatlich
Risk management
Clemens Moll
Beauftragte für Risiko- und Qualitätsmanagement
Am Vogelherd 14
88239 Wangen
Phone:
07522
-797-1109
Fax: 07522-797-1118
Mail:
ed.nekinilk-zw@llom.snemelc
Beteiligte der QM-Steuergruppe sind: jeweils ein ärztlicher und nichtärztlicher Vertreter aller Kliniken (Abteilungen) Krankenhausdirektor Hygienefachkraft Betriebsrat
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Verfahrensanweisung einrichtungsinternes Risiko- und Qualitätsmanagement (19.07.2019) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management VA Notfallmanagement (23.01.2020) |
| RM05 |
Pain management Postoperative Schmerztherapie (03.12.2019) |
| RM06 |
Fall prophylaxis Sturzprophylaxe in der Pflege (19.02.2020) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitus - Risikoeinschätzung abgeleitet von der Bradenskala (23.09.2020) |
| RM08 |
Regulated handling of custodial measures Verfahrensanweisung "Freiheitsbeschränkende Maßnahmen" (22.02.2019) |
| RM09 |
Regulated handling of occurring malfunctions of devices Umsetzung der MP-BetreibV in den Fachkliniken Wangen (08.08.2019) |
| 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 Perioperatives Management (03.12.2019) |
| RM15 |
Preoperative, complete presentation of necessary findings Perioperatives Management (03.12.2019) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Operatives Management (03.12.2019) |
| RM17 |
Standards for recovery and postoperative care Checkliste Verlegung (04.05.2019) |
| RM18 |
Discharge management Entlassmanagement_Akut (18.04.2019) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Im Risikomanagement-Konzept sind Verantowrtlichkeiten sowie Strategien und Insturmente zur Steigerung der Patientensicherheit festgelegt
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 30.09.2021 |
| 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 bei Bedarf |
Conference committee
Conference frequency: monatlich
| 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) |