Dealing with risks in patient care
Quality management
Anja Schlieder
Leitung Qualitätsmanagement
Landhausstraße 25
69115 Heidelberg
Phone:
06221
-526-501
Mail:
ed.suahneknarksfesoj.ts@tnemeganamsteatilauq
Geschäftsführung, Ärztlicher Direktor, Pflegedirektorin und Leitung Qualitätsmanagement
Conference frequency: bei Bedarf
Risk management
Anja Schlieder
Leitung Qualitätsmanagement
Landhausstraße 25
69115 Heidelberg
Phone:
06221
-526-501
Fax: 06221-526-959
Mail:
ed.suahneknarksfesoj.ts@tnemeganamsteatilauq
Geschäftsführung, Ärztlicher Direktor, Pflegedirektorin und Leitung Qualitätsmanagement
Conference frequency: bei Bedarf
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Intranet, QM-Handbuch (01.01.2022) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Medizinisches Notfallmanagement im St. Josefskrankenhaus; SOP Versorgung Notfallpatienten (01.06.2023) |
| RM05 |
Pain management Schmerztherapie (AN_M1 - AN_M15) (15.07.2021) |
| RM06 |
Fall prophylaxis Ablaufpfad Sturz (PFLEGE_P1_0002) (01.07.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Intranet, QM-Handbuch (01.01.2022) |
| RM08 |
Regulated handling of custodial measures Antrag und Zeugnis FEM; Amtsgericht Heidelberg (01.08.2021) |
| 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 WHO-OP-Sicherheits-Checkliste (CH_M2) (22.03.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings WHO-OP-Sicherheits-Checkliste (CH_M2) (22.03.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups WHO-OP-Sicherheit-Checkliste (CH_M2); SOP Vermeidung von Eingriffsverwechslungen (CH_M27) (22.03.2023) |
| RM17 |
Standards for recovery and postoperative care Intranet, QM-Handbuch (01.01.2022) |
| RM18 |
Discharge management Ablaufpfad Entlassmanagement (01.07.2021) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
seit 2014: WHO-OP-Sicherheitscheckliste in den operativen Fachabteilungen seit 2014: Einsatz von Patientenidentifikationsarmbändern September 2019: Teilnahme am internationalen Patientensicherheitstag mit verschiedenen internen Aktionen, Infoständen und Filmen
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.05.2021 |
| 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 halbjährlich |
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) |