Dealing with risks in patient care
Quality management
Frau Julia Neuberger
Qualitätsmanagementbeauftragte
Am Griesberg 1
84347 Pfarrkirchen
Phone:
08721
-983-2120
Mail:
ed.nekinilknnilattor@ailuj.regrebuen
Das Qualitätsmanagement der Rottal-Inn Kliniken ist als Stabsstelle dem Vorstand unterstellt. Es erfolgt hier eine enge Zusammenarbeit mit allen Abteilungen der Rottal-Inn Kliniken. Entscheidungen im Rahmen des Qualitätsmanagements werden in direkter Absprache mit dem Vorstand getroffen.
Conference frequency: wöchentlich
Risk management
Julia Neuberger
Qualitätsmanagementbeauftragte
Am Griesberg 1
84347 Pfarrkirchen
Phone:
08721
-983-2120
Fax: 08721-983-2124
Mail:
ed.nekinilknnilattor@ailuj.regrebuen
Vorstände, Qualitätsmanagement, Pflegedirektorin, Ärztlicher Direktor, Abteilungsleiter Finanzen und Patientenmanagement, Abteilungsleiter Zentraleinkauf/Technik/Wirtschafts- und Versorgungsdienst, Personalleiter sowie weitere Fachexperten bei Bedarf
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, Handbuch Risikomanagement (25.07.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Alarm-und Einsatzplan, Notfallorganisation (12.06.2023) |
| RM05 |
Pain management Empfehlungen zur Schmerztherapie (02.05.2023) |
| RM06 |
Fall prophylaxis Expertenstandard Sturzprophylaxe in der Pflege (29.06.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitusprophylaxe (21.12.2021) |
| RM08 |
Regulated handling of custodial measures Fixierungsdienstanweisung (10.11.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Dienstanweisung Medizintechnik (23.09.2022) |
| 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 Perioperative Checkliste (09.07.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings Perioperative Checkliste (09.07.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Perioperative Checkliste, Endoskopie Checkliste (09.07.2021) |
| RM17 |
Standards for recovery and postoperative care Standards im Aufwachraum (27.07.2021) |
| RM18 |
Discharge management Einwilligungen/Patienteninformation/Initialassessment (08.05.2023) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Es konnten in verschiedenen Bereichen der Kliniken Themen aus gemeldeten Fehlern und Beinahe-Fehlern heraus verbessert werden.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 05.05.2023 |
| 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 bei Bedarf |
Conference committee
Conference frequency: andere Frequenz
| 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) |