Die Risikosteuergruppe setzt sich aus dem technischen, kaufmännischen und klinischen Risikomanagement zusammen. Darüber hinaus ist die Risikokommission interprofessionell und interdisziplinär besetzt.

Conference frequency: quartalsweise

Risk management instruments and measures

Instruments and measures

No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM-Konzept; Risikomanagement-Handbuch; Risikokatalog; Risikobericht (19.04.2022)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management VA Notfallmanagement (15.10.2018)
RM05	Pain management VA Schmerzmanagement (04.05.2018)
RM06	Fall prophylaxis VA Vermeidung von Sturzereignissen (08.10.2019)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) VA Dekubitusprophylaxe (08.10.2019)
RM08	Regulated handling of custodial measures VA Freiheitsentziehende Maßnahmen (15.11.2019)
RM09	Regulated handling of occurring malfunctions of devices Organisationshandbuch Medizinprodukte und Medizintechnik (31.03.2021)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen
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 OP-Checkliste, Team Time-Out (16.03.2017)
RM15	Preoperative, complete presentation of necessary findings OP-Checkliste, Team Time-Out (16.03.2017)
RM16	Procedure to avoid procedural and patient mix-ups OP Checkliste, VA Patientenidentifikationsarmbänder, VA Lenkung von Fehlern, Risiken, Vorbeugungs- und Korrekturmaßnahmen (12.05.2021)
RM17	Standards for recovery and postoperative care Behandlungspfade (29.05.2017)
RM18	Discharge management VA Sozialdienst/AHB (04.05.2021)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

- Erstellung oder Aktualisierung von Verfahrensanweisungen - Prozessoptimierungen - Überprüfung von Prozessen im Rahmen von internen Audits - Sensibilisierung bzw. Schulung der Mitarbeiter - Anschaffung neuer Medizingeräte

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 28.06.2021
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

No.

Explanation

IF01

Documentation and procedural instructions for handling the error reporting system are available

As of: 28.06.2021

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

Across all institutions

Conference committee

Conference frequency: monatlich

No.	Explanation
	Other
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)

No.

Explanation

Other

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)