Dealing with risks in patient care
Quality management
Tom Jahn
Qualitätsmanagementbeauftragter
Germeringer Straße 32
82152 Planegg
Phone:
089
-85693-2566
Mail:
ed.pmku@nhaj
Vertreter jeder Abteilung / jedes Funktionsbereichs
Conference frequency: quartalsweise
Risk management
Astrid Klinger
Chefärztin Anäshesie
Germeringer Straße 32
82152 Planegg
Phone:
089
-85693-2518
Fax: 089-85693-2118
Mail:
ed.pmku@regnilk
Vertreter jeder Abteilung / jedes Funktionsbereichs
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitätsmanagementhandbuch (15.11.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Qualitätsmanagementhandbuch (15.11.2023) |
| RM05 |
Pain management Qualitätsmanagementhandbuch (15.11.2023) |
| RM06 |
Fall prophylaxis Qualitätsmanagementhandbuch (15.11.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Qualitätsmanagementhandbuch (15.11.2023) |
| RM08 |
Regulated handling of custodial measures Qualitätsmanagementhandbuch (15.11.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Qualitätsmanagementhandbuch (15.11.2023) |
| 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 Qualitätsmanagementhandbuch (15.11.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings Qualitätsmanagementhandbuch (15.11.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Qualitätsmanagementhandbuch (15.11.2023) |
| RM17 |
Standards for recovery and postoperative care Qualitätsmanagementhandbuch (15.11.2023) |
| RM18 |
Discharge management Qualitätsmanagementhandbuch (15.11.2023) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Erhöhung der Arzneimittelsicherheit durch klinisch pharmazeutische Beratung durch Krankenhausapothekerin, Weiterbildung Antibiotic Stewards, elektronisch gestützter Aufklärungsprozess, IT-gestützte Medikationsunterstützung, Armbänder zur Patientenidentifikation
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 15.11.2023 |
| IF02 |
Internal evaluation of the received reports taken bei Bedarf |
| IF03 |
Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken monatlich |
Conference committee
Conference frequency: bei Bedarf
| 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) |