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Klinikum Ingolstadt

Dealing with risks in patient care

Quality management

Responsible person

Simone R. Wagner

Abteilungsleiterin Qualitäts- und Risikomanagement

Krumenauerstraße 25
85049 Ingolstadt

Phone: 0841 -880-0
Mail: ed.tdatslogni-mukinilk@rengaw.enomis

Steering committee

Abteilung Qualitäts- und Risikomanagement. Darüber hinaus Besprechungen mit Kliniken, Zentren, Stationen und Abteilungen. Des Weiteren vierteljährlich interdisziplinäre Qualitätszirkel.

Conference frequency: andere Frequenz

Risk management

Responsible person

Simone R. Wagner

Abteilungsleiterin Qualitäts- und Risikomanagement

Krumenauerstraße 25
85049 Ingolstadt

Phone: 0841 -880-0
Mail: ed.tdatslogni-mukinilk@rengaw.enomis

Steering committee

Pflegedienstleitung, Qualitätsmanagement, ausgebildete Risikomanager, Oberärzte, Stationsleiter

Conference frequency: monatlich

Risk management instruments and measures

Instruments and measures

No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available VA-Risikomanagement (28.07.2020)
RM02	Regular further education and training measures
RM04	Clinical emergency management PB-ZOP Notfallmanagement (03.09.2019)
RM05	Pain management INF-MU Schmerzschema (09.05.2022)
RM06	Fall prophylaxis PB Sturzmanagement (10.02.2020)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) SOP-Dekubitusprophylaxe in der Pflege (18.11.2019)
RM08	Regulated handling of custodial measures SOP-PP Pflegeleitlinie: Fixierung (02.07.2019)
RM09	Regulated handling of occurring malfunctions of devices VA-medizintechnische Geräte (16.07.2018)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Pathologiebesprechungen Palliativbesprechungen Klinik-Gespräche
RM12	Use of standardised information sheets
RM13	Application of standardised surgical check lists
RM15	Preoperative, complete presentation of necessary findings FO-OP Patientensicherheit (22.07.2021)
RM16	Procedure to avoid procedural and patient mix-ups VA-Patientenarmband (20.07.2021)
RM18	Discharge management Entlassmanagement-Prozess-Standard für das Klinikum Ingolstadt (28.05.2021)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

CIRS-Meldungen werden bearbeitet und bei Bedarf Maßnahmen umgesetzt. Die Koordination und Umsetzung der Maßnahmen erfolgte durch ein interdisziplinäres Team.

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 07.04.2021
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 jährlich

No.

Explanation

IF01

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

As of: 07.04.2021

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 jährlich

Across all institutions

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)