Dealing with risks in patient care
Quality management
Dipl. Pflegewirt (FH) Michael Rettner
Leitung Qualitätsmanagement & klinisches Risikomanagement
Rathsberger Straße 57
91054 Erlangen
Phone:
09131
-822-3468
Mail:
ed.suahneknarkdlaw@rentter.leahcim
Ärztliches QM, Pflegedienstleitung, Oberarzt, QM Beschwerdemanagement, Versorgungsmanagement , MAV
Conference frequency: quartalsweise
Risk management
Michael Rettner
Leitung Qualitätsmanagement & klinisches Risikomanagement
Rathsberger Straße 57
91054 Erlangen
Phone:
09131
-822-3468
Fax: 09131-822-4101
Mail:
ed.suahneknarkdlaw@rentter.leahcim
QM, Ärztlicher Dienst, PDL, Verwaltung
Conference frequency: halbjährlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Zentrale Dokumentenlenkung (Curator) (25.09.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Zentrale Dokumentenlenkung (Curator) (25.09.2023) |
| RM05 |
Pain management SOP Schmerztherapie / Regionalanästhesie (08.04.2021) |
| RM06 |
Fall prophylaxis Standard Sturzprophylaxe (29.01.2018) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) VA Dekubitusprophylaxe (28.04.2023) |
| RM08 |
Regulated handling of custodial measures VA Freiheitsentziehende Maßnahmen (31.01.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Zentrale Dokumentenlenkung (Curator) (25.09.2023) |
| 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 Planungsmodul im KIS Checkliste Patientensicherheit (16.11.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings SOP Checkliste Patientensicherheit (16.11.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups SOP Checkliste Patientensicherheit (u.a.) (16.11.2021) |
| RM17 |
Standards for recovery and postoperative care Zentrale Dokumentenlenkung (Curator) (25.09.2023) |
| RM18 |
Discharge management Zentrale Dokumentenlenkung (Curator) (25.09.2023) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Erarbeitung von Standards und Checklisten, Nutzung von Patientenidentifikationsarmbändern, Fort- und Weiterbildungsmaßnahmen durchführen, Etablierung von Indikationsbesprechungen und Komplikationsbesprechungen, Laufende Optimierung von Prozessen und viele weitere.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 12.11.2020 |
| IF02 |
Internal evaluation of the received reports taken monatlich |
| 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) |