Dealing with risks in patient care
Quality management
Dipl-Kfm. (FH) Markus Kaiser
Leiter Qualitätsmanagement
Jürgensallee 46-48
22609 Hamburg
Phone:
040
-82281-0
Mail:
ed.htugrd@resiakm
Ärztlicher Dienst, Pflegedienst, Verwaltung, Betriebsrat, Beschwerdebeauftragte
Conference frequency: quartalsweise
Risk management
Markus Kaiser
Leiter Qualitätsmanagement
Jürgensallee 46-48
22609 Hamburg
Phone:
040
-82281-0
Fax: 040-82281-193
Mail:
ed.htugrd@resiakm
Ärztlicher Dienst, Pflegedienst, Verwaltung, Betriebsrat, Beschwerdebeauftragte
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available KO Risiko- und Fehlermanagement (28.08.2020), PB Besonderes Vorkommnis und CIRS (17.02.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management PB Verhalten bei Patientennotruf und Patientennotfall (13.10.2022) |
| RM05 |
Pain management AA Algorithmus Akutschmerztherapie (08.11.2022) |
| RM06 |
Fall prophylaxis PB Sturzmanagement (19.10.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) MIN Dekubituspropylaxe (20.05.2021) |
| RM08 |
Regulated handling of custodial measures PB Freiheitsentziehende Maßnahmen (11.08.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices KO Qualitätshandbuch MPDG (17.10.2022) |
| 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 PB Patientensicherheit vor operativen Eingriffen (27.10.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings CL Patientensicherheit vor operativen Eingriffen (27.10.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups CL Patientensicherheit vor operativen Eingriffen (27.10.2023) |
| RM17 |
Standards for recovery and postoperative care PS Postoperative Versorgung (12.10.2021) |
| RM18 |
Discharge management PB Entlassmanagement (19.10.2022) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
- Modernisierung der Lichtrufanlage - Fahrstuhlsanierung - Umstellung der Flächendesinfektion nach aktueller RKI-Richtlinie - Compliancebeobachtung von Mitarbeitenden - Beratungsgespräche für Patienten und Angehörige durch HFK zu multiresistenten Erregern - Weiterentwicklung des klinikgruppenweit gültigen Fehler- und Risikomanagementkonzeptes
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 17.02.2022 |
| IF02 |
Internal evaluation of the received reports taken bei Bedarf |
| 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: