Dealing with risks in patient care
Quality management
Kristin Michallik
Referentin der Geschäftsführung
Eitzer Straße 20
27283 Verden (Aller)
Phone:
04231
-103-5021
Mail:
ed.kinilk-resew-rella@killahcim.k
Geschäftsführung / Krankenhausleitung / Qualitätsmanagement
Conference frequency: monatlich
Risk management
Kristiane Langer
Externe Risikomanagerin
Eitzer Straße 20
27283 Verden (Aller)
Phone:
04231
-103-5000
Fax: 04231-103-7340
Mail:
ed.kinilk-resew-rella@regnal.k
Geschäftsführung / Ärztlicher Direktor / Pflegedirektion / Verwaltungsdirektion / externe Risikomanagerin, Qualitätsmanagerin
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Strategiepapier Risikomanagement (2016) (15.09.2022) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management VA Notfallmanagement - Konzept innerklinischer Notfall 2021 (15.04.2021) |
| RM05 |
Pain management Schmerzstandard zur Behandlung akuter Schmerzen und Schema Schmerztherapie (11.03.2020) |
| RM06 |
Fall prophylaxis VA Umgang mit Stürzen (08.05.2019) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) VA Dekubitusprophylaxe (08.05.2019) |
| RM08 |
Regulated handling of custodial measures AWK VA Freiheitsentziehende Maßnahmen, inkl. Fixierungsprotokoll (07.08.2020) |
| RM09 |
Regulated handling of occurring malfunctions of devices VA Umgang mit Medizinprodukten (20.03.2021) |
| 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 VA Team-Time-Out und Perioperative Checkliste / OP-Statut (08.01.2019) |
| RM15 |
Preoperative, complete presentation of necessary findings VA Team-Time-Out und Perioperative Checkliste (Team-Time-Out -Checkliste) (01.04.2020) |
| RM16 |
Procedure to avoid procedural and patient mix-ups VA Identifikationsarmband, VA Vermeidung von Verwechslungen im OP (24.09.2020) |
| RM17 |
Standards for recovery and postoperative care Aufwachraumstandards, postoperative Überwachung, AA Verlegung AWR (1.0) (15.06.2021) |
| RM18 |
Discharge management VA Entlassung (4.0) (08.03.2018) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Klinikbezogene CIRS-Gruppen (eine berufsgruppenübergreifend besetzte Gruppe pro Fachklinik
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 22.01.2018 |
| 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 |
|---|---|
| EF03 |
KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors) |