Dealing with risks in patient care
Quality management
Jürgen Holub
Qualitätskoordinator
Kösinger Straße 11
73450 Neresheim
Phone:
07326
-9608-0
Mail:
ed.hrs@buloh.negreuj
Krankenhausleitungskonferenz: Geschäftsführung, Ärztlicher Direktor, Chefärztin, Verwaltungsleitung, Pflegedienstleitung, Personalleitung, QM-Koordinator.
Conference frequency: monatlich
Risk management
Jürgen Holub
Qualitätskoordinator
Phone:
07326
-9608-0
Fax: 07326-9608-115
Mail:
ed.hrs@buloh.negreuj
Krankenhausleitungskonferenz: Geschäftsführung, Ärztlicher Direktor, Chefärztin, Verwaltungsleitung, Pflegedienstleitung, Personalleitung, QM-Koordinator.
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Prozessmodell FKNe (14.11.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Notfallalarm AA (19.10.2020) |
| RM05 |
Pain management Klinikkonzept SRH Fachkrankenhaus Neresheim (11.05.2016) |
| RM06 |
Fall prophylaxis PST 031 Surzprophylaxe (22.03.2017) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) PST 005 Dekubitus- Thrombose- Pneumonie- Soor- und Parotitisprophylaxe (05.06.2019) |
| RM08 |
Regulated handling of custodial measures Freiheitsentziehende Maßnahmen (FEM) (03.04.2017) |
| RM09 |
Regulated handling of occurring malfunctions of devices Bedienungsanleitung Störmeldemodul MedTech (17.01.2023) |
| 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 Ablauf AA (16.12.2019) |
| RM15 |
Preoperative, complete presentation of necessary findings OP Ablauf AA (16.12.2019) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Prozessmodell FKNe (14.11.2023) |
| RM17 |
Standards for recovery and postoperative care OP Ablauf AA (16.12.2019) |
| RM18 |
Discharge management Prozessmodell FKNe (14.11.2023) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Wöchentliche Überprüfung der Herzalarmanlage auf den Stationen. Jährliche Auswertung der Sturzrate und Art des Sturzes durch den Arzt. Einsatz von sog. Klingelmatten bei bestimmten Patientenklientel.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 09.01.2013 |
| 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 |
|---|---|
| EF03 |
KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors) |