Dealing with risks in patient care
Quality management
Christina Schmock
Qualitätsmanagerin
Wildeshauser Straße 92
27753 Delmenhorst
Phone:
04221
-99-5566
Mail:
ed.mukinilk-emled@kcomhcs.c
Klinikdirektor, QM-Verantwortliche, Leitung Medizin-Controlling, Oberarzt Allgemeinchirurgie, Pflegedienstleitung
Conference frequency: monatlich
Risk management
Christina Schmock
Qualitätsmanagerin
Wildeshauser Straße 92
27753 Delmenhorst
Phone:
04221
-99-5566
Mail:
ed.mukinilk-emled@kcomhcs.c
Klinikdirektor, QM-Verantwortliche, Leitung Medizin-Controlling, Oberarzt Allgemeinchirurgie, Pflegedienstleitung
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Notfallmanagement - Das Notfall-Team im DKD (23.04.2020) |
| RM05 |
Pain management SOP Akutschmerztherapie (14.09.2023) |
| RM06 |
Fall prophylaxis Sturzprophylaxe (23.03.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusprophylaxe (27.11.2020) |
| RM08 |
Regulated handling of custodial measures VA zu freiheitsenziehenden Maßnahmen (23.04.2020) |
| 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 Team Timeout (11.10.2019) |
| RM15 |
Preoperative, complete presentation of necessary findings Indikationsbesprechung am Nachmittag vor dem OP-Tag, OP-Checkliste (11.10.2019) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Verschiedene VA zur Patientenidentifikation, Op-Checklisten etc. (11.10.2019) |
| RM17 |
Standards for recovery and postoperative care postoperative anästhesiologische Versorgung, letzte Aktualisierung 03.01.2022 postoperative Versorgung von Patienten mit hüftgelenknaher Femurfraktur, letzte Aktualisierung 12.01.2021 (12.01.2021) |
| RM18 |
Discharge management VA Ausstellung der Verordnung von Medikamenten und Heil-/Hilfsmitteln (27.03.2018) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Fehler und Beinahefehler können von jedem Mitarbeiter anonymisiert gemeldet werden. Sie werden innerhalb von 14 Tage vom CIRS-Team bearbeitet.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 10.01.2022 |
| IF02 |
Internal evaluation of the received reports taken jährlich |
| 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: jährlich
| No. | Explanation |
|---|---|
|
Other |
|
| EF03 |
KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors) |