Dealing with risks in patient care
Quality management
Diplom-Kaufmann (FH) Mark Stab
Leiter Qualitätsmanagement, klinisches Risikomanagement, Tumordokumentation und Zentralarchiv
Robert-Koch-Str. 2
25524 Itzehoe
Phone:
04821
-772-4200
Mail:
ed.eohezti-hk@bats.m
Qualitätskommission mit dem Vorstand des Klinikums.
Conference frequency: quartalsweise
Risk management
Mark Stab
Leiter Qualitätsmanagement, klinisches Risikomanagement, Tumordokumentation und Zentralarchiv
Phone:
04821
-772-4200
Fax: 04821-772-974200
Mail:
ed.eohezti-hk@bats.m
Im Rahmen einer Risikokommission werden zweiwöchentlich Risiken und CIRS-Fälle bearbeitet. Die Kommission ist interdisziplinär und interprofessionell besetzt.
Conference frequency: andere Frequenz
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM-Handbücher, Verfahrensanweisungen, Arbeitsanweisungen, Standards, Checklisten...... (27.10.2017) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management QM-Handbücher, Verfahrensanweisungen, Arbeitsanweisungen, Standards, Checklisten...... (27.10.2017) |
| RM05 |
Pain management QM-Handbücher, Verfahrensanweisungen, Arbeitsanweisungen, Standards, Checklisten...... (27.10.2017) |
| RM06 |
Fall prophylaxis QM-Handbücher, Verfahrensanweisungen, Arbeitsanweisungen, Standards, Checklisten...... (27.10.2017) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) QM-Handbücher, Verfahrensanweisungen, Arbeitsanweisungen, Standards, Checklisten...... (27.10.2017) |
| RM08 |
Regulated handling of custodial measures QM-Handbücher, Verfahrensanweisungen, Arbeitsanweisungen, Standards, Checklisten...... (27.10.2017) |
| RM09 |
Regulated handling of occurring malfunctions of devices QM-Handbücher, Verfahrensanweisungen, Arbeitsanweisungen, Standards, Checklisten...... (27.10.2017) |
| 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 QM-Handbücher, Verfahrensanweisungen, Arbeitsanweisungen, Standards, Checklisten...... (27.10.2017) |
| RM15 |
Preoperative, complete presentation of necessary findings QM-Handbücher, Verfahrensanweisungen, Arbeitsanweisungen, Standards, Checklisten...... (27.10.2017) |
| RM16 |
Procedure to avoid procedural and patient mix-ups QM-Handbücher, Verfahrensanweisungen, Arbeitsanweisungen, Standards, Checklisten...... (27.10.2017) |
| RM17 |
Standards for recovery and postoperative care QM-Handbücher, Verfahrensanweisungen, Arbeitsanweisungen, Standards, Checklisten...... (27.10.2017) |
| RM18 |
Discharge management QM-Handbücher, Verfahrensanweisungen, Arbeitsanweisungen, Standards, Checklisten...... (27.10.2017) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
- Patientenarmbänder und Checkliste zur Patientensicherheit (WHO) - Interdisziplinäre Morbiditäts- und Mortalitätskonferenz
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 10.02.2015 |
| 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 |
|---|---|
| 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) |