Dealing with risks in patient care
Quality management
Dipl. - Kffr. (FH) Birgit Stühmeier
QMB, Assistentin des Verwaltungsdirektors
Renatastr. 71A
80639 München
Phone:
089
-1304-2215
Mail:
ed.noitkeridsuahneknark@reiemheuts.tigrib
Verwaltungsdirektor und QMB
Conference frequency: quartalsweise
Risk management
Birgit Stühmeier
QMB, Assistentin des Verwaltungsdirektors
Phone:
089
-1304-2215
Mail:
ed.noitkeridsuahneknark@reiemheuts.tigrib
Krankenhausleitung - RM
Conference frequency: bei Bedarf
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitätsmanagementhandbuch (31.03.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Qualitätsmanagementhandbuch Herzkreislaufstillstand - Reanimation (SOP_54) Stand 10/2021Reanimationsstandard Notfallkonzept (KO_34) Stand 12/2021 Rea-Protokoll (FO_284) Stand: 04/2021 (20.12.2021) |
| RM05 |
Pain management Qualitätsmanagementhandbuch Ergotherapie Schmerzmanagment (IN_3) (30.10.2022) |
| RM06 |
Fall prophylaxis Qualitätsmanagementhandbuch Sturzprophylaxe (ST_12) Stand 11/2021 Sturzereignis (ST_11) Stand 04/2023 Patienteninfo zur Sturzprophylaxe (IN_6) Stand 10/2021 (18.04.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Qualitätsmanagementhandbuch ST_9 (24.02.2020) |
| RM08 |
Regulated handling of custodial measures Qualitätsmanagementhandbuch Freiheitsentziehende Maßnahmen (FEM) (ST_57) Stand 06/2021 Dokumentation FEM (FO_194) Stand 04/2023 Antrag FEM Briefvorlaqge (FO_61) Stand 03/2023 (30.03.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Organisationshandbuch Medizintechnik (01.08.2012) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM16 |
Procedure to avoid procedural and patient mix-ups Checkliste Patientensicherheit Checkliste Endoskopie Untersuchungsprotokoll (FO_64) Stand 06/2023 Patientenidentifikation mit Armbändern (VA_165) Stand 03/2022 Patientenidentifikation (AA_103) Stand 03/2022 (01.06.2023) |
| RM18 |
Discharge management Entlassmanagement - Entlassplan (FO_129) Entlassplanung (LF_5) (25.01.2022) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Anpassung / Optimierung von Prozessen, Schulungen für das Personal, technische Änderungen wie zum Beispiel Schnittstellen zwischen den Krankenhausinformationssystemen geschaffen, Patietenidentifikation/-armbänder
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.05.2021 |
| IF02 |
Internal evaluation of the received reports taken bei Bedarf |
| 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: