Dealing with risks in patient care
Quality management
Kerstin Womelsdorf
Qualitätsmanagementbeauftragte-Assistentin der Geschäftsführung
Barlstraße 3-7
56856 Zell/Mosel
Phone:
06542
-97-0
Mail:
ed.lesomlettim-mukinilk@ofni
Geschäftsführung, Ärztlicher Direktor, Kfm. Direktion, Pflegedirektion
Conference frequency: andere Frequenz
Risk management
Geschäftsführung, Ärztlicher Direktor, Kfm. Direktion, Pflegedirektion
Conference frequency: andere Frequenz
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Elektronisches Organisationshandbuch (27.10.2022) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Konzept Medizinisches Notfallmanagement (15.01.2018) |
| RM05 |
Pain management Verfahrensanweisung Schmerztherapie und Arbeitsanweisung Schmerzmanagement in der Pflege (16.10.2014) |
| RM06 |
Fall prophylaxis Standard Sturzprophylaxe (03.05.2018) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitusprophylaxe, Standard Einschätzung Dekubitus, Meldung Dekubitus (18.11.2016) |
| RM08 |
Regulated handling of custodial measures Konzept im Umgang mit freiheitsentziehenden Maßnahmen (FEM) (18.11.2016) |
| RM09 |
Regulated handling of occurring malfunctions of devices Organisationshandbuch Medizinprodukte (24.08.2017) |
| 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 Patient Blood Management; maschinelle Autotransfusion (Cellsaver) (18.11.2016) |
| RM15 |
Preoperative, complete presentation of necessary findings Fallbesprechungen, Checkliste Team-Time-Out (17.03.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Arbeitsanweisung Patientenidentifikation (18.11.2016) |
| RM17 |
Standards for recovery and postoperative care Checkliste Übergabe eines Patienten aus dem Aufwachraum (18.11.2016) |
| RM18 |
Discharge management Konzept Entlassmanagement, Stationsstatut Innere Medizin (08.02.2021) |
Fault reporting systems
Conference committee
Conference frequency: andere Frequenz
Measures
- Patientenarmbänder für alle stationären Patienten - Checkliste Team-Time-Out im OP (modifiziert nach WHO) - Anästhesie Checklisten - Verfahrensanweisung Schockraum - Checkliste HKL
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 27.10.2022 |
| 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 bei Bedarf |
Conference committee
Conference frequency: andere Frequenz
| 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) |