Dealing with risks in patient care
Quality management
Norbert Lambertz
Leiter Stabsstelle Qualitätsmanagement
Stoffelsberg 4
86720 Nördlingen
Phone:
09082
-79-0
Mail:
ed.nekinilknod@ztrebmal.n
Vorstand, Ärztlicher Direktor, Verwaltungsleitung, Pflegedienstleitung; Leitung Personalabteilung, Personalrat, Qualitätsmanagementbeauftragte
Conference frequency: quartalsweise
Risk management
Norbert Lambertz
Leiter Stabsstelle Qualitätsmanagement
Stoffelsberg 4
86720 Nördlingen
Phone:
09082
-79-0
Fax: 09082-79-32002
Mail:
ed.nekinilknod@ztrebmal.n
CIRS-Gruppe: Oberarzt Chirurgie, Chef- und Oberarzt Anästhesie, Oberarzt Innere Mediziin; Pflegefachkraft, Qualitätsmanagementbeauftragte
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM-Dokumentation (05.07.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management QM-Dokumentation (05.07.2023) |
| RM05 |
Pain management QM-Dokumentation (05.07.2023) |
| RM06 |
Fall prophylaxis QM-Dokumentation (05.07.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) QM-Dokumentation (05.07.2023) |
| RM08 |
Regulated handling of custodial measures QM-Dokumentation (05.07.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices QM-Dokumentation (05.07.2023) |
| 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 im Rahmen der Aufklärung und OP-Planung (05.07.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings OP-Besprechung (05.07.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups QM-Dokumentation (05.07.2023) |
| RM17 |
Standards for recovery and postoperative care QM-Dokumentation (05.07.2023) |
| RM18 |
Discharge management QM-Dokumentation (05.07.2023) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Anonymer CIRS- Meldebogen im Intranet, durch alle Mitarbeiter anonym nutzbar, zentrale Bearbeitung über die Stabsstelle Qualitätsmanagement
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 05.07.2023 |
| IF02 |
Internal evaluation of the received reports taken quartalsweise |
| 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 |
|---|---|
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |