Dealing with risks in patient care
Quality management
Thorsten Hauptvogel
Abteilungsleiter Qualitätsmanagement
Gutleutstraße 1-14
76646 Bruchsal
Phone:
07141
-99-60042
Mail:
ed.nekinilk-hkr@legovtpuah.netsroht
Geschäftsleitung, Ärztliche Direktoren, Pflegedirektion, Qualitätsmanagement, Betriebsrat
Conference frequency: monatlich
Risk management
Thorsten Hauptvogel
Abteilungsleiter Qualitätsmanagement
Gutleutstraße 1-14
76646 Bruchsal
Phone:
07141
-99-60042
Mail:
ed.nekinilk-hkr@legovtpuah.netsroht
Geschäftsleitung, Ärztliche Direktoren, Pflegedirektion, Qualitätsmanagement, Betriebsrat
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available RL Risikomanagement 07-00 RKH (24.04.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management ST Durchführung Notfallmanagement KLK 06-00; SO Alarmdefinition-Alarmschleifen FSK 01-00 (09.02.2023) |
| RM05 |
Pain management VA Schmerzmanagement 06-00 RKH (15.11.2022) |
| RM06 |
Fall prophylaxis VA Sturzmanagement 06-00 RKH (30.11.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) VA Dekubitusmanagement 04-00 RKH (20.04.2021) |
| RM08 |
Regulated handling of custodial measures VA Freiheitsentziehende Maßnahmen 03-00 RKH (03.12.2020) |
| RM09 |
Regulated handling of occurring malfunctions of devices VA (Beinahe-) Vorkommnisse Medizinprodukte 06-00 RKH 2022-06-02 VA MPG Rueckruf von Medizinprodukten 05-00 RKH 2021-03-19 (02.06.2022) |
| 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 CL Sicherheit bei Invasiven Eingriffen RKH 07-00 (05.06.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings CL Sicherheit bei Invasiven Eingriffen RKH 07-00 (05.06.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups DA Umgang mit der Checkliste Invasive Eingriffe 01-00 RKH (30.07.2021) |
| RM17 |
Standards for recovery and postoperative care DV OP-Statut FSK 05-00 (01.07.2022) |
| RM18 |
Discharge management VA Entlassmanagement 03-00 RKH (01.06.2022) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
z..B. Patienten-Safty-Card
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 19.10.2021 |
| 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 quartalsweise |
Conference committee
Conference frequency: monatlich
| No. | Explanation |
|---|---|
| EF02 |
CIRS Berlin (Medical Association Berlin, German Medical Association, National Association of Statutory Health Insurance Doctors) |