Dealing with risks in patient care
Quality management
Diana Friede
Leiterin Stabsstelle Qualitätsmanagement/Risikomanagement
Girbigsdorfer Straße 1-3
02828 Görlitz
Phone:
03581
-37-3051
Mail:
ed.ztilreog-mukinilk@anaid.edeirf
Geschäftsführung, Krankenhausdirektion, Qualitätsmanagement, Unternehmenskommunikation, Compliance, Innenrevision
Conference frequency: wöchentlich
Risk management
Diana Friede
Leiterin Stabsstelle Qualitätsmanagement/Risikomanagement
Girbigsdorfer Straße 1-3
02828 Görlitz
Phone:
03581
-37-3051
Fax: 03581-37-1556
Mail:
ed.ztilreog-mukinilk@anaid.edeirf
Qualitätsmanagement, Innenrevision, Compliance, Medizinische Direktion, Kaufmännische Direktion, Technischer Dienst, Pflegedienst, Krankenhaushygiene
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Dienstanweisung Risikomanagement (02.09.2019) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Behandlung von Notfallpatienten (01.03.2022) |
| RM05 |
Pain management Schmerzmanagement (13.10.2021) |
| RM06 |
Fall prophylaxis Sturzprophylaxe (13.06.2020) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusprophylaxe (21.05.2021) |
| RM08 |
Regulated handling of custodial measures Anwendung von Sicherungsmaßnahmen gegen den Willen des Patienten (03.04.2019) |
| RM09 |
Regulated handling of occurring malfunctions of devices Dienstanweisung Umgang mit medizintechnischen Geräten (15.09.2012) |
| 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 Verhinderung der Operation am falschen Operationsgebiet, am falschen Patienten oder mittels des falschen OP-Verfahrens (11.01.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings Standard OP-Vorbereitung (10.02.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Korrekte Identifikation des Patienten (27.03.2018) |
| RM17 |
Standards for recovery and postoperative care Verfahrensanweisung Aufwachraum (12.02.2018) |
| RM18 |
Discharge management Entlassmanagement (18.07.2020) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
z.B. korrekte Identifizierung des Patienten, Team Time out vor der OP, Sturzprävention, Vermeidung nosokomialer Infektionen, Fehlerfreie Kommunikation, Maßnahmen zur Verhinderung von Verwechslungen bei Konzentraten
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 13.03.2013 |
| 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: bei Bedarf
| No. | Explanation |
|---|---|
|
Other |