Dealing with risks in patient care
Quality management
Stefanie Schmidbartl
Sekretariat, Qualitätsmanagement
Waldstraße 7
82166 Gräfelfing
Phone:
089
-8587-140
Mail:
ed.kinilktraflow@ltrabdimhcs
Die Klinikleitungsmitglieder treffen sich wöchentlich um aktuelle Themen zu besprechen.
Conference frequency: wöchentlich
Risk management
Stefanie Schmidbartl
Sekretariat, Qualitätsmanagement
Waldstraße 7
82166 Gräfelfing
Phone:
089
-8587-140
Fax: 089-8587-204
Mail:
ed.kinilktraflow@ltrabdimhcs
Das Risikomanagement ist bei der Klinikleitung angesiedelt. Alle Meldungen aus dem Risikomeldesystem gehen an die Klinikleitung und werden in der wöchentlichen Klinikleitungssitzung bearbeitet. Hierbei werden Maßnahmen, Konsequenzen in Bezug auf die Risikoreduktion beschlossen und umgesetzt
Conference frequency: wöchentlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM-Handbuch (18.04.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management QM-Handbuch (18.04.2023) |
| RM05 |
Pain management QM-Handbuch (18.04.2023) |
| RM06 |
Fall prophylaxis QM-Handbuch (18.04.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) QM-Handbuch (18.04.2023) |
| RM08 |
Regulated handling of custodial measures QM-Handbuch (18.04.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices QM-Handbuch (18.04.2023) |
| 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 QM-Handbuch (18.04.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings QM-Handbuch (18.04.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups QM-Handbuch (18.04.2023) |
| RM17 |
Standards for recovery and postoperative care QM-Handbuch (18.04.2023) |
| RM18 |
Discharge management QM-Handbuch (18.04.2023) |
Fault reporting systems
Conference committee
Conference frequency: wöchentlich
Measures
4-Augen-Prinzip bei der Bewertung der Eingangsmedikation, Vermeidung von Patientenverwechslungen durch mehrmalige Abfrage der Personendaten,Vermeidung von Seitenverwechslungen durch mehrmalige Kontrollen, Anwendung einer OP-Sicherheits-Checkliste
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 18.04.2023 |
| 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 bei Bedarf |
Conference committee
Conference frequency: wöchentlich
| No. | Explanation |
|---|---|
|
Other |