Dealing with risks in patient care

Quality management

Bianca Neysters

Verwaltungsleiterin

Diekseepromenade 7-11
23714 Bad Malente-Gremsmühlen

Phone: 04523 -405-0
Mail: ed.kinilk-reib-tsugua@sretsyen

QM-Lenkungsausschuss: Verwaltungsleiterin, Pflegedienstleitung, Chefarzt, Betriebsrat, Qualitätsbeauftragte/r.

Conference frequency: monatlich

Risk management

Jos Becktepe

Chefarzt

Diekseepromenade 7-11
23714 Bad Malente-Gremsmühlen

Phone: 04523 -405-110
Fax: 04523-405-100
Mail: ed.kinilk-reib-tsugua@epetkceb

Ärzteteam, Physiotherapie und Pflegedienst

Conference frequency: wöchentlich

Risk management instruments and measures

No. Explanation
RM01

Comprehensive quality and/or risk management documentation (QM/RM documentation) is available

QM-Konzept; Konzept für das Ciritcal Incidents Reporting System (CIRS), Risikomanagement in der AUGUST-BIER-KLINIK. (01.09.2022)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Notfall-Management-System, inklusive mitgeltender Informationen (24.04.2023)

RM05

Pain management

Verfahrensrichtlinie Schmerzmanagement; inklusive mitgeltender Informationen (15.08.2023)

RM06

Fall prophylaxis

Konzept zur Sturzprophylaxe und Sturzmanagement, inklusive mitgeltender Informationen (03.01.2023)

RM07

Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”)

Dekubitusprophylaxe (21.03.2023)

RM08

Regulated handling of custodial measures

Regelungen zu freiheitsentziehenden Maßnahmen (19.05.2022)

RM09

Regulated handling of occurring malfunctions of devices

Konzept Medizinprodukte (18.09.2023)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Teambesprechung
  • Frühbesprechung
  • Fallbesprechung "Sturz"
  • Fallbesprechung "Wunde"
RM12

Use of standardised information sheets

RM17

Standards for recovery and postoperative care

Prä- und postoperative Versorgung einer PEG-Anlage (20.01.2022)

RM18

Discharge management

Entlassmanagement (16.12.2022)

Fault reporting systems

Conference committee

Conference frequency: wöchentlich

Measures

Verfahrensrichtlinie (MM) mit entsprechender Nachweisdokumentation zum Umgang mit dem Fehlermeldesystem liegen vor.

No. Explanation
IF01

Documentation and procedural instructions for handling the error reporting system are available

As of: 01.09.2022

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 jährlich

Conference committee

Conference frequency: jährlich

No. Explanation
EF03

KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors)