Dealing with risks in patient care

Quality management

Achim Klemm

Leitung Qualitätsmanagement

Kroonhorst 11
22549 Hamburg

Phone: 040 -181886-2297
Mail: moc.soipelksa@mmelk.ca

Klinikleitung, Qualitätsmanagement, Pflegedirektion, Chefärzte

Conference frequency: monatlich

Risk management

Rudolf Töpper

Ärztlicher Direktor, Chefarzt der Neurologie


21041 Hamburg

Phone: 040 -181886-2552
Fax: 040-181876-3092
Mail: moc.soipelksa@reppeot.r

Klinikleitung, Qualitätsmanagement, Pflegedirektion, Chefärzte

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

Comprehensive quality and/or risk management documentation (QM/RM documentation) is available

Konzept Klinisches Risikomanagement (15.01.2021)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Verfahrensanweisung (19.06.2020)

RM05

Pain management

Verfahrensanweisung (10.08.2020)

RM06

Fall prophylaxis

Verfahrensanweisung (18.05.2020)

RM07

Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”)

Verfahrensanweisung (03.06.2019)

RM08

Regulated handling of custodial measures

Verfahrensanweisung (21.07.2021)

RM09

Regulated handling of occurring malfunctions of devices

Verfahrensanweisung (29.09.2019)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Palliativbesprechungen
  • Psychiatrische Fallbesprechungen
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

Verfahrensanweisung (21.08.2020)

RM15

Preoperative, complete presentation of necessary findings

Verfahrensanweisung (21.08.2020)

RM16

Procedure to avoid procedural and patient mix-ups

Verfahrensanweisung (24.02.2022)

RM17

Standards for recovery and postoperative care

Überwachungsbogen (21.08.2020)

RM18

Discharge management

Verfahrensanweisung (11.06.2021)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Sicherheitschecklisten, Austausch von risikoträchtigen Materialien, Verbesserungen Kommunikation und Prozesse

No. Explanation
IF01

Documentation and procedural instructions for handling the error reporting system are available

As of: 13.05.2020

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

Other

EF14

CIRS Health Care