Dealing with risks in patient care

Quality management

Angelika Jakolow-Standke

Leitung Qualitäts- und Risikomanagement

Warener Straße 7
12683 Berlin

Phone: 030 -5681-1159
Mail: ed.bku@ekdnats-wolokaj.akilegna

Qualitätsmanagementbeauftragte der Kliniken und Leitung Qualitäts- und Risikomanagement

Conference frequency: jährlich

Risk management

Angelika Jakolow-Standke

Leitung Qualitäts- und Risikomanagement

Warener Straße 7
12683 Berlin

Phone: 030 -5681-1159
Fax: 030-5681-3003
Mail: ed.bku@ekdnats-wolokaj.akilegna

Vertreter des Ärztlichen Dienstes, des Pflegedienstes und der Verwaltung

Conference frequency: halbjährlich

Risk management instruments and measures

No. Explanation
RM01

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

Risikomanagement-Handbuch (14.04.2022)

RM02

Regular further education and training measures

RM04

Clinical emergency management

VA Reanimationen im ukb (11.01.2022)

RM05

Pain management

Expertenstandard Schmerzmanagement (28.09.2022)

RM06

Fall prophylaxis

Expertenstandard Sturzmanagement (22.02.2022)

RM07

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

Expertenstandard Dekubitusprophylaxe (28.08.2019)

RM08

Regulated handling of custodial measures

Konzept Freiheitsentziehende Maßnahmen (09.06.2022)

RM09

Regulated handling of occurring malfunctions of devices

VA (21.05.2019)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Pathologiebesprechungen
  • Palliativbesprechungen
  • 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

OP-Statut (18.10.2018)

RM16

Procedure to avoid procedural and patient mix-ups

Risikomanagement-Handbuch (14.04.2022)

RM17

Standards for recovery and postoperative care

Risikomanagement-Handbuch (14.04.2022)

RM18

Discharge management

Expertenstandard Entlassungsmanagement (21.02.2022)

Fault reporting systems

Conference committee

Conference frequency: bei Bedarf

Measures

Verwendung von Patientenidentifikationsbänder, Maßnahmenpaket zum Expertenstandard Sturzprophylaxe - Aufklärungsflyer "Stürze sind vermeidbar"

No. Explanation
IF01

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

As of: 14.04.2022

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: quartalsweise

No. Explanation
EF02

CIRS Berlin (Medical Association Berlin, German Medical Association, National Association of Statutory Health Insurance Doctors)