Dealing with risks in patient care
Quality management
Judith Emich
Qualitätsbeauftragte
Albert-Schweitzer-Straße 40 - 44
14974 Ludwigsfelde
Phone:
03378
-828-2148
Mail:
ed.suahnessinokaid@hcime.htiduj
Kaufmännische Direktion, Pflegedirektion, Ärztliche Direktion, Geschäftsführung, Zentrales Qualitätsmanagement, lokales Qualitätsmanagement
Conference frequency: monatlich
Risk management
Burkhard Schult
Ärztlicher Direktor, Prozessverantwortlicher für das Klinische Risikomanagement
Phone:
03378
-828-2406
Fax: 03378-828-2404
Mail:
ed.suahnessinokaid@tluhcs.drahkrub
Vorstand, Geschäftsführung, Klinikleitung, Risikokoordinator
Conference frequency: jährlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikomanagementhandbuch und Risikoatlas (11.11.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Diverse fachspezifische Dokumente zum Notfallmanagement, u.a. Interdisziplinäre Schockraumleitlinie (04.07.2021) |
| RM05 |
Pain management Experten Standard (01.10.2022) |
| RM06 |
Fall prophylaxis Sturzprophylaxe in der PflegeExpertenstandard (10.10.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Handbuch Dekubitusmanagement (12.10.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Störmeldung Fa. Vamed (15.10.2022) |
| 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 OP-Patientensicherheit (18.09.2020) |
| RM15 |
Preoperative, complete presentation of necessary findings Risikomanagementhandbuch und Risikoatlas (11.11.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Risikomanagementhandbuch und Risikoatlas (11.11.2022) |
| RM17 |
Standards for recovery and postoperative care Kriterien für die Entlassung aus dem Aufwachraum (28.11.2018) |
| RM18 |
Discharge management Entlassmanagement und mitgeltende Dokumente (27.11.2021) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Schulungsmaßnahmen
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 26.01.2023 |
| 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: 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) |