Dealing with risks in patient care
Quality management
Dipl. - Kffr. (FH) Birgit Stühmeier
QMB
Renatastr. 71A
80639 München
Phone:
089
-1304-2215
Mail:
ed.noitkeridsuahneknark@reiemheuts.tigrib
Verwaltungsdirektor und QMB
Conference frequency: quartalsweise
Risk management
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 12/2021) Reanimationsstandard Notfallkonzept (KO_34 Stand 12/2021) (20.12.2021) |
| RM05 |
Pain management Ergotherapie Schmerzmanagement (IN_3 Stand 08/2022) (01.08.2022) |
| RM06 |
Fall prophylaxis Sturzprophylaxe (ST_12 Stand 11/2023) 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”) Dekubitusprophylaxe- Expertenstandard (ST_9 Stand 02/2020) Dekubituserfassung (FO_19 Stand 06/2021) (01.06.2021) |
| RM08 |
Regulated handling of custodial measures Freiheitsentziehende Maßnahmen (FEM) (ST_57) Stand 06/2021) Dokumentation FEM (FO_194 Stand 02/2023) Antrag FEM Briefvorlaqe (FO_61 Stand 04/2023) (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 Checklisten: Endoskopie Untersuchungsprotokoll (FO_64 Stand 06/2023) Untersuchungsprotokoll Herzkatheter (FO_333 Stand 06/2024) Patientenidentifikation mit Armbändern (VA_165 Stand 03/2022) Patientenidentifikation (AA_103 Stand 03/2022) (01.06.2024) |
| RM18 |
Discharge management Entlassmanagement - Entlassplan (FO_129 Stand 01/2022) Entlassplanung (LF_5 Stand 03/2018) (25.01.2022) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Anpassung / Optimierung von Prozessen, Schulungen für das Personal, Patientensicherheit: Patientenidentifikation/-armbänder
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 12.12.2022 |
| 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: