To the hospital’s home page

Marienkrankenhaus Kassel

Dealing with risks in patient care

Quality management

Responsible person

Gabriele Riedl

Unternehmensentwicklung/Qualitätsmanagement

Marburger Str. 85
34127 Kassel

Phone: 0561 -8073-1007
Mail: ed.lessak-suahneknarkneiram@ldeir.g

Steering committee

Standortübergreifende QM-Steuerungsgruppe. Teilnehmer: QMBs beider Standorte, Geschäftsführer, Pflegedirektion, Leitung Personalabteilung, ärztlicher Direktor

Conference frequency: quartalsweise

Risk management

Responsible person

Gabriele Riedl

Unternehmensentwicklung/Risikomanagement

Phone: 0561 -8073-1007
Fax: 0561-8073-4000
Mail: ed.lessak-suahneknarkneiram@ldeir.g

Steering committee

Standortübergreifende QM-Steuerungsgruppe. Teilnehmer: QMBs beider Standorte, Geschäftsführer, Pflegedirektion, Leitung Personalabteilung, ärztlicher Direktor

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 Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2022)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2022)
RM05	Pain management Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2022)
RM06	Fall prophylaxis Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2022)
RM08	Regulated handling of custodial measures Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2022)
RM09	Regulated handling of occurring malfunctions of devices Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2022)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Palliativbesprechungen Pathologiebesprechungen Qualitätszirkel Indikationsbesprechung; CED-Konferenzen; strukt. Röntgenbesprechungen
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 Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2022)
RM15	Preoperative, complete presentation of necessary findings Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2022)
RM16	Procedure to avoid procedural and patient mix-ups Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2022)
RM17	Standards for recovery and postoperative care Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2022)
RM18	Discharge management Risikomanagement-Handbuch, Qualitätsmanagement-Handbuch (19.12.2022)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Fortbildungsangebote wurden angepasst; Fallkonferenzen weiterentwickelt; Im Rahmen der Digitalisierung weitere Tools z.B. im Rahmen der Arzneimittelsicherheit eingeführt

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 23.03.2022
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: 23.03.2022

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)