Dealing with risks in patient care
Quality management
Stefan Seeholzer
Leitung Abteilung Zentrale Dienste (Stabstellen QM, RM, BM, UM, Arbeitssicherheit, Datenschutz, MPG)
Bgm.-Dr.-Hartmann-Str. 50
86899 Landsberg am Lech
Phone:
08191
-333-1345
Mail:
ed.grebsdnal-mukinilk@rezlohees.nafets
Vorstand, ärztlicher Direktor, Pflegedirektor, Leitung zentrale Dienste
Conference frequency: jährlich
Risk management
Stefan Seeholzer
Leitung zentrale Dienste - Qualitäts-, Risiko- und Beschwerdemanagement
Bgm.-Dr.-Hartmann-Str. 50
86899 Landsberg am Lech
Phone:
08191
-333-1346
Fax: 08191-333197-1543
Mail:
ed.grebsdnal-mukinilk@rezlohees.nafets
PaSIS-Beauftragte aus den jeweiligen Fachabteilungen und der RM-Beauftragte des Hauses
Conference frequency: bei Bedarf
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikomanagement-Strategie (09.03.2023) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Hausweites Qualitätsmanagementhandbuch, Hausweite Risikomanagement-Strategie (09.03.2023) |
| RM05 |
Pain management Medikamentöse Schmerzstandards (19.11.2024) |
| RM06 |
Fall prophylaxis Expertenstandard Sturz (04.11.2024) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitusprohylaxe (04.11.2024) |
| RM08 |
Regulated handling of custodial measures Dienstanweisung "Fixierung" (05.11.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices Dienstanweisung Umgang mit Medizinprodukten (19.04.2022) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM13 |
Application of standardised surgical check lists |
| RM16 |
Procedure to avoid procedural and patient mix-ups Risikoatlas, Risikomanagementhandbuch (09.03.2023) |
| RM17 |
Standards for recovery and postoperative care Versorgungsstandards Aufwachraum (18.01.2023) |
| RM18 |
Discharge management Entlassmanagement (23.05.2024) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Einführung von Komplikationsbesprechungen, Integration von Risikokontrollpunkten in die Prozessabläufe, kontinuierliche Überwachung mittels interner Risikoaudits
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 31.05.2022 |
| 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 monatlich |
Conference committee
Conference frequency: bei Bedarf
| No. | Explanation |
|---|---|
| EF15 |
PaSIS (Patient Safety and Information System of the University Hospital Tübingen) |