Dealing with risks in patient care
Quality management
Betriebswirt (VWA) Christine Rebiger
Qualitätsmanagementbeauftragte
Klützer Winkel 13-15
23932 Grevesmühlen
Phone:
03841
-331411-
Mail:
ed.anas@regiber.enitsirhc
Geschäftsführung, Ärztlicher Direktor, Pflegedirektorin, Leitung Personalabteilung, Betriebsrat, QMB
Conference frequency: quartalsweise
Risk management
Christine Rebiger
Qualitätsmanagementbeauftragte
Klützer Winkel 13-15
23932 Grevesmühlen
Phone:
03841
-331411-
Mail:
ed.anas@regiber.enitsirhc
Geschäftsführung, Ärztlicher Direktor, Pflegedirektorin, Leitung Personalabteilung, Betriebsrat, QMB
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM-Handbuch (31.10.2021) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Medizinische Notfälle (05.07.2020) |
| RM05 |
Pain management QM-Handbuch (08.08.2020) |
| RM06 |
Fall prophylaxis Sturzprophylaxe (15.09.2020) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) QM-Handbuch (26.10.2020) |
| RM08 |
Regulated handling of custodial measures Fixierung (06.09.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices QM-Handbuch (01.11.2022) |
| 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 OP-Statut (06.09.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings OP-Statut (06.09.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups OP-Statut (06.09.2021) |
| RM17 |
Standards for recovery and postoperative care OP-Statut (06.09.2021) |
| RM18 |
Discharge management va Entlassmanagement (15.07.2021) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Maßnahmeableitung erfolgt nach Bedarf
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 11.10.2021 |
| 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 jährlich |
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) |