Dealing with risks in patient care
Quality management
Anne Wellbrock
Qualitätsmanagement
In der Vahr 65
28329 Bremen
Phone:
0421
-4683-403
Mail:
ed.dkp@kcorbllew.enna
Ärztliche Fachgebietsleitungen, Pflegedienstleitung, Qualitätsbeauftragte, Abteilungsleitungen
Conference frequency: quartalsweise
Risk management
Nadine Qela
Qualitätsbeauftragte
In der Vahr 65
28329 Bremen
Phone:
0421
-4683-403
Fax: 0421-4683-396
Mail:
ed.dkp@aleq.enidan
Ärztliche Fachgebietsleitungen, Pflegedienstleitung, Qualitätsbeauftragte, Abteilungsleitungen
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitätssicherungsstatut (03.05.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Notfallmanagement (12.09.2023) |
| RM05 |
Pain management Konzept Schmerzmanagement (12.09.2023) |
| RM06 |
Fall prophylaxis Expertenstandard Sturzprophylaxe (12.09.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitusprophylaxe in der Pflege (12.09.2023) |
| RM08 |
Regulated handling of custodial measures Leitfaden Fixierung von Patienten (22.08.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Richtlinie zum Umgang mit Medizinprodukten (13.09.2023) |
| 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 Qualitäts- und Risikomanagement "Checkliste OP Vorbereitung und Patientensicherheit OP" (02.08.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings Checkliste vorstationärer Tag (06.09.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Anwendung der Sicherheitscheckliste OP in Anlehnung gemäß dem Aktionsbündnis Patientensicherheit (02.08.2023) |
| RM17 |
Standards for recovery and postoperative care Medikamentengabe und Überwachung im AWR (13.09.2023) |
| RM18 |
Discharge management Prozess Entlassungsmanagement (13.09.2023) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Anpassung von Einarbeitungskatalogen für Ärzte und Pflege, OP-Checkliste, Team Time out, CIRS medical, Interne Schulungen zum Thema Patientensicherheit, Schulung der Mitarbeiter zu hauseigenen Fehlermeldesystemen
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 15.09.2023 |
| 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 halbjährlich |
Conference committee
Conference frequency: monatlich
| 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) |