Dealing with risks in patient care
Quality management
Anja Tscherne
Qualitätsmanagement - Risikomanagement
Romanstraße 93
80639 München
Phone:
089
-1797-1717
Mail:
ed.nehcneum-egizrehmrab@enrehcst.ajna
Manfred Laufer
Leiter Organisationsentwicklung und Patientensicherheit
Romanstraße 93
80639 München
Phone:
089
-1797-1807
Mail:
ed.nehcneum-egizrehmrab@refual.derfnam
In unserem Krankenhaus werden in den regelmäßigen Direktoriumssitzungen alle Qualitätsmanagement-Themen diskutiert und notwendige Entscheidungen getroffen. Zudem tagt in einem zweimonatigen Abstand das interprofessionelle und interdisziplinäre Entwicklungsteam.
Conference frequency: andere Frequenz
Risk management
Anja Tscherne
Qualitätsmanagement - Risikomanagement
Romanstraße 93
80639 München
Phone:
089
-1797-1717
Fax: 089-1797-905086
Mail:
ed.nehcneum-egizrehmrab@enrehcst.ajna
Das Patientensicherheitsteam setzt sich aus Vertretern der Kliniken, der Geschäftsführung, der Pflegedienstleitung und der Abteilung für Organisationsentwicklung und Patientensicherheit zusammen. Tagungen nach Bedarf, mindestens quartalsweise.
Conference frequency: andere Frequenz
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available BB Klinisches Risikomanagementkonzept (18.09.2018) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Handbuch Notfallzentrum; VA Medizinischer Notfall, Interdisziplinäre Notfallgruppe unter Leitung der Anästhesie (05.01.2023) |
| RM05 |
Pain management VA Schmerztherapie (11.03.2020) |
| RM06 |
Fall prophylaxis Expertenstandard Sturzprophylaxe (30.10.2019) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitusprophylaxe (30.10.2019) |
| RM08 |
Regulated handling of custodial measures SOP Freiheitseinschränkende Maßnahmen (04.11.2019) |
| RM09 |
Regulated handling of occurring malfunctions of devices VA Umgang mit MPG AA implantierbare Medizinprodukte (22.09.2020) |
| 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 OP Handbuch; TTO (Team Time Out); OP-Checklisten, WHO-Checklisten (12.12.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings OP Handbuch; TTO (Team Time Out), WHO-Checklisten (12.12.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups OP Handbuch; AA Patientenidentifikationsarmband, WHO-Checklisten (12.12.2022) |
| RM17 |
Standards for recovery and postoperative care OP Handbuch, Checkliste OP-Sicherheit (12.12.2022) |
| RM18 |
Discharge management AA Entlassmanagement (AU-Bescheinigung, Leifaden, Medikation, Verordnung Heil- und Hilfsmittel), VA Entlassmanagement (02.05.2018) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Risikomanagement (CIRS), Beschwerdemanagement, Fehlermanagement, interne und externe Audits (Begehungen), Risikoaudits, Risikoanalysen
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 22.03.2021 |
| IF02 |
Internal evaluation of the received reports taken quartalsweise |
| 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: bei Bedarf
| No. | Explanation |
|---|---|
|
Other |
|
| EF01 |
CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association, National Association of Statutory Health Insurance Doctors) |
| EF03 |
KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors) |