Dealing with risks in patient care
Quality management
Dipl. Gesundheitsökonomin Kristin Zapf
QMB
Albert-Schweitzer-Straße 2
98527 Suhl
Phone:
03681
-35-5013
Mail:
ed.hrs@fpaz.nitsirk
Geschäftsführung, ärztliche und pflegerische Direktion
Conference frequency: quartalsweise
Risk management
Die Steuergruppe setzt sich aus QM, ärztlicher Leiter und Leiter Apotheke leiten die Steuergruppe, 2 OÄ aus Risikobereichen, 2 MA der Pflegedirektion, MA Medizintechnik/IT und 1 Vertreter des Betriebsrates zusammen.
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available CIRS Critical-Incident Reporting System (18.03.2021) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Notfallmanagement (11.10.2022) |
| RM05 |
Pain management Expertenstandard Schmerz (09.06.2023), Postoperative Schmerztherapie (10.06.2023) (09.06.2023) |
| RM06 |
Fall prophylaxis Expertenstandard Sturz (15.06.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitusprophylaxe (28.03.2023) |
| RM08 |
Regulated handling of custodial measures Fixierungsrichtlinie (05.12.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Handbuch Medizinprodukte (10.06.2023) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM13 |
Application of standardised surgical check lists |
| RM15 |
Preoperative, complete presentation of necessary findings CIRS Critical-Incident Reporting System (18.03.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Perioper. Sicherheitscheckliste (18.03.2021) |
| RM17 |
Standards for recovery and postoperative care SOP Patientenüberwachung im Aufwachraum (11.10.2022) |
| RM18 |
Discharge management Expertenstandard Entlassungsmanagement (06.09.2023) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
flächendeckender Einsatz von Patientenarmbändern, Etablierung der WHO-Checkliste, Patientenaufklärung (Dokumentation), elektronische Verordnungsunterstützung, Pflichtfortbildungen wie Reanimation etc.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.04.2021 |
| IF02 |
Internal evaluation of the received reports taken halbjährlich |
| 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) |