Dealing with risks in patient care
Quality management
Bianca Neysters
Verwaltungsleiterin
Diekseepromenade 7-11
23714 Bad Malente-Gremsmühlen
Phone:
04523
-405-0
Mail:
ed.kinilk-reib-tsugua@sretsyen
QM-Lenkungsausschuss: Verwaltungsleiterin, Pflegedienstleitung, Chefarzt, Betriebsrat, Qualitätsbeauftragte/r.
Conference frequency: monatlich
Risk management
Jos Becktepe
Chefarzt
Diekseepromenade 7-11
23714 Bad Malente-Gremsmühlen
Phone:
04523
-405-110
Fax: 04523-405-100
Mail:
ed.kinilk-reib-tsugua@epetkceb
Ärzteteam, Physiotherapie und Pflegedienst
Conference frequency: wöchentlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM-Konzept; Konzept für das Ciritcal Incidents Reporting System (CIRS), Risikomanagement in der AUGUST-BIER-KLINIK. (01.09.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Notfall-Management-System, inklusive mitgeltender Informationen (24.04.2023) |
| RM05 |
Pain management Verfahrensrichtlinie Schmerzmanagement; inklusive mitgeltender Informationen (15.08.2023) |
| RM06 |
Fall prophylaxis Konzept zur Sturzprophylaxe und Sturzmanagement, inklusive mitgeltender Informationen (03.01.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusprophylaxe (21.03.2023) |
| RM08 |
Regulated handling of custodial measures Regelungen zu freiheitsentziehenden Maßnahmen (19.05.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Konzept Medizinprodukte (18.09.2023) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM17 |
Standards for recovery and postoperative care Prä- und postoperative Versorgung einer PEG-Anlage (20.01.2022) |
| RM18 |
Discharge management Entlassmanagement (16.12.2022) |
Fault reporting systems
Conference committee
Conference frequency: wöchentlich
Measures
Verfahrensrichtlinie (MM) mit entsprechender Nachweisdokumentation zum Umgang mit dem Fehlermeldesystem liegen vor.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.09.2022 |
| 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: jährlich
| 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) |