Dealing with risks in patient care
Quality management
Dipl. Pflegewirtin (FH) Mechthild Ammermann
stellv. Pflegedirektorin/Leiterin Qualitäts- und Risikomanagement
Stadtrandstraße 555
13589 Berlin
Phone:
030
-3702-2322
Mail:
ed.dsj@nnamremmA.dlihthceM
In unserer zentralen Arbeitsgruppe, QM Team, sind aus jeder Fachabteilung des Hauses Vertreter/Vertreterinnen benannt.
Conference frequency: quartalsweise
Risk management
Mechthild Ammermann
stellv. Pflegedirektorin/Leiterin Qualitäts- und Risikomanagement
Phone:
030
-3702-2322
Fax: 030-3702-2037
Mail:
ed.dsj@nnamremmA.dlihthceM
In unserer zentralen Arbeitsgruppe, QM Team, sind aus jeder Fachabteilung des Hauses Vertreter/Vertreterinnen benannt.
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM Handbuch - aktuelle Fassung (06.04.2021) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management QM Handbuch (06.04.2021) |
| RM05 |
Pain management QM Handbuch (06.04.2021) |
| RM06 |
Fall prophylaxis QM Handbuch (05.06.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) QM Handbuch (04.06.2021) |
| RM08 |
Regulated handling of custodial measures QM Handbuch - aktuelle Fassung (06.04.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices QM Handbuch - aktuelle Fassung (05.06.2021) |
| 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 QM Handbuch - aktuelle Fassung (06.04.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings QM Handbuch - aktuelle Fassung (07.08.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups QM Handbuch - aktuelle Fassung (09.04.2020) |
| RM17 |
Standards for recovery and postoperative care QM Handbuch - aktuelle Fassung (09.04.2021) |
| RM18 |
Discharge management QM Handbuch - aktuelle Fassung (06.04.2021) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Im Rahmen des QM Teams werden alle CIRS Meldungen analysiert, bewertet und Maßnahmen angeleitet. Auf Holdingebene werden die CIRS Meldungen riskobewertet und kommentiert.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 09.04.2018 |
| 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 jährlich |
Conference committee
Conference frequency: monatlich
| No. | Explanation |
|---|---|
| EF02 |
CIRS Berlin (Medical Association Berlin, German Medical Association, National Association of Statutory Health Insurance Doctors) |