Dealing with risks in patient care

Quality management

Caterina Mambou

Leitung Qualitätsmanagement

Haselkamp 33
22359 Hamburg

Phone: 040 -64411-8587
Mail: ed.nenitreblaleunammi@uobmam.aniretac

Geschäftsführung und Qualitätsmanagement, bei Bedarf in weiteren Gremien (Direktorium, Chefarzt- oder Pflegeleitungskonferenz)

Conference frequency: monatlich

Risk management

Caterina Mambou

Leitung Qualitätsmanagement

Phone: 040 -64411-8587
Mail: ed.nenitreblaleunammi@uobmam.aniretac

Caterina Mambou

Leitung Qualitätsmanagement

Phone: 040 -64411-8587
Mail: ed.nenitreblaleunammi@uobmam.aniretac

Geschäftsführung und Qualitätsmanagement, bei Bedarf in weiteren Gremien (Direktorium, Chefarzt- oder Pflegeleitungskonferenz)

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

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

Teil der QM/RM-Dokumentation (14.06.2023)

RM02

Regular further education and training measures

RM04

Clinical emergency management

Teil der QM/RM-Dokumentation (06.07.2022)

RM05

Pain management

Teil der QM/RM-Dokumentation (15.12.2021)

RM06

Fall prophylaxis

Teil der QM/RM-Dokumentation (22.06.2023)

RM07

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

Teil der QM/RM-Dokumentation (06.07.2022)

RM08

Regulated handling of custodial measures

Teil der QM/RM-Dokumentation (15.12.2021)

RM09

Regulated handling of occurring malfunctions of devices

Teil der QM/RM-Dokumentation (02.02.2023)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
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

Teil der QM/RM-Dokumentation (15.06.2023)

RM15

Preoperative, complete presentation of necessary findings

Teil der QM/RM-Dokumentation (15.06.2023)

RM16

Procedure to avoid procedural and patient mix-ups

Teil der QM/RM-Dokumentation (15.06.2023)

RM17

Standards for recovery and postoperative care

Teil der QM/RM-Dokumentation (15.06.2023)

RM18

Discharge management

Teil der QM/RM-Dokumentation (14.07.2023)

Fault reporting systems

Conference committee

Conference frequency: quartalsweise

Measures

Risiko-Workshops, Schulungen, Erweiterung der OP-Checkliste, Sturzstatistik, digitale Kurve

No. Explanation
IF01

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

As of: 19.07.2022

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 halbjährlich

Conference committee

Conference frequency: quartalsweise

No. Explanation

Other