Dealing with risks in patient care
Quality management
Frau Carsta Seidel
Qualitätsmanagerin
Stadionbrücke 4
30459 Hannover
Phone:
--
Mail:
ed.hrk@ledies.atsrac
interdisziplinärer Qualitätszirkel, je Organkrebszentrum und im Krebszentrum, Interne Steuerungsgruppen, Berufsgruppenvertretungen, standortbezogenen Qualitätszirkel onkologische Fachpflege und standortübergreifend Qualitätsmultiplikatoren Treffen, Organisationsentwicklungstreffen
Conference frequency: monatlich
Risk management
Zentrale Steuerungsgruppe
Conference frequency: halbjährlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available RM 01 (15.02.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management RM 04 (22.02.2022) |
| RM05 |
Pain management RM 05 (02.03.2022) |
| RM06 |
Fall prophylaxis RM 06 (02.03.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) RM 07 (02.03.2022) |
| RM08 |
Regulated handling of custodial measures RM 08 (06.04.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices RM 09 (06.05.2022) |
| 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 RM14 (03.03.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings RM 15 (02.11.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups RM 16 (02.11.2021) |
| RM17 |
Standards for recovery and postoperative care RM 17 (04.11.2021) |
| RM18 |
Discharge management RM 18 (03.11.2021) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
CIRS vollumfänglich eingeführt im gesamten KH Siloah
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 22.02.2022 |
| 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:
| No. | Explanation |
|---|---|
|
Other |