Dealing with risks in patient care
Quality management
Kathrin Bergmoser
Qualitätsmanagementbeauftragte
Konrad-Regler-Straße 1
85110 Kipfenberg
Phone:
08465
-175-504
Mail:
ed.tiehdnuseg-demav@resomgreb.nirhtak
Geschäftsführung, Ärztlicher Dienst, Pflege, Therapie, Hygiene, Datenschutz, Qualitätsmanagement, Risikomanagement, Betriebstechnik
Conference frequency: monatlich
Risk management
Peter Kugler
Prozessmanagement / Risikomanagementbeauftragter
Phone:
08465
-175-66140
Fax: 08465-175-111
Mail:
ed.tiehdnuseg-demav@relguk.retep
Geschäftsführung, Ärztlicher Dienst, Pflege, Therapie, Hygiene, Datenschutz, Qualitätsmanagement, Risikomanagement, Betriebstechnik
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available VB Risikomanagement (25.05.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management KHAEP, Anlage C.22 - stat. Notfallmanagement (30.03.2023) |
| RM05 |
Pain management Handlungsempfehlung Schmerzmanagement in der Pflege bei akuten und chronischen Schmerzen - https://md-bund.de/themen/pflegequalitaet/expertenstandards-in-der-pflege.html (01.06.2022) |
| RM06 |
Fall prophylaxis ST_Sturzprophylaxe (13.04.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) ST_Dekubitusprophylaxe (09.08.2022) |
| RM08 |
Regulated handling of custodial measures VA_Freiheitsentziehende Maßnahmen (15.03.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Organisationshandbuch Medizintechnik (21.10.2022) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM13 |
Application of standardised surgical check lists |
| RM14 |
Preoperative summary of predictable critical surgical steps, surgical time and expected blood loss LL_Vorgehen vor PEG- bzw. JET-PEG-Anlage (30.10.2019) |
| RM15 |
Preoperative, complete presentation of necessary findings LL_Vorgehen vor PEG- bzw. JET-PEG-Anlage (30.10.2019) |
| RM16 |
Procedure to avoid procedural and patient mix-ups LL_Vorgehen vor PEG- bzw. JET-PEG-Anlage (30.10.2019) |
| RM17 |
Standards for recovery and postoperative care LL_Vorgehen nach PEG-Anlage (01.06.2023) |
| RM18 |
Discharge management VB Entlassmanagement (09.02.2022) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
1. Medikamentenumstellung Fentanypflaster 2. Produktumstellung Sauerstoffsensoren 3. Verlängerung Beleuchtungszeit Treppenhäuser 4. Verdichtung einer Schiebetür zwischen Patientenzimmern
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 06.09.2022 |
| 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 bei Bedarf |
Conference committee
Conference frequency: bei Bedarf
| No. | Explanation |
|---|---|
|
Other |