Dealing with risks in patient care

Quality management

Frau Johanna Schmidt

QM-Beauftragte

Fuhrberger Straße 8
30938 Burgwedel

Phone: 0511 -9179-7960
Mail: ed.hrk@ledewgrubssorg.ledatdnubol

Regelhaft: - Direktorium - Chefärzte - Pflegedienstleitung - Bereichsleitungen - Fachabteilungen - QMB's der Standorte - QM-Multiplikatoren - Zertifizierte Zentren

Conference frequency: monatlich

Risk management

Britta Dodenhof

QM Beauftragte und klinische Risikomanagerin


30929 Burgwedel

Phone: --
Mail: ed.hrk@fohnedod.attirb

Regelhaft: - Direktorium - Chefärzte - Pflegedienstleitung - Bereichsleitungen - Fachabteilungen - QMB's der Standorte - QM-Multiplikatoren - Zertifizierte Zentren

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

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

DLS (Dokumentenlenkungssytem), Intrafox Risikomanagement, klinisches Risikomanagement (26.07.2022)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

DLS (Dokumentenlenkungssytem), Intrafox Risikomanagement, klinisches Risikomanagement (26.07.2022)

RM05

Pain management

DLS (Dokumentenlenkungssytem), Intrafox Risikomanagement, klinisches Risikomanagement (26.07.2022)

RM06

Fall prophylaxis

SAP und DLS (13.03.2023)

RM07

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

Intranet und DLS (12.12.2018)

RM08

Regulated handling of custodial measures

Dokumentation im Intranet (24.05.2022)

RM09

Regulated handling of occurring malfunctions of devices

Richtlinie Medizintechnik im DLS (46446) (17.05.2021)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Qualitätszirkel
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

DLS (Dokumentenlenkungssytem), Intrafox Risikomanagement, klinisches Risikomanagement (26.07.2022)

RM15

Preoperative, complete presentation of necessary findings

DLS (Dokumentenlenkungssytem), Intrafox Risikomanagement, klinisches Risikomanagement (26.07.2022)

RM16

Procedure to avoid procedural and patient mix-ups

DLS (Dokumentenlenkungssytem), Intrafox Risikomanagement, klinisches Risikomanagement (26.07.2022)

RM17

Standards for recovery and postoperative care

DLS (Dokumentenlenkungssytem), Intrafox Risikomanagement, klinisches Risikomanagement (26.07.2022)

RM18

Discharge management

Prozessbeschreibung Entlassungsmanagement zur Zeit im Intranet (09.10.2017)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Konzernweites, webbasiertes CIRS

No. Explanation
IF01

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

As of: 15.11.2022

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: bei Bedarf

No. Explanation

Other