Dealing with risks in patient care
Quality management
QM-Lenkungsgremium (Stabsstelle QM + Krankenhausleitung) und QM-Arbeitskreis (Stabsstelle QM + interdisziplinäre Teilnehmende)
Conference frequency: monatlich
Risk management
Andreas Kelpe
Ltr. QM
Bahnhofstraße 2-4
99867 Gotha
Phone:
03601
-803-841
Fax: 03601-803-266
Mail:
ed.kheo@mq
QM-Lenkungsgremium (Stabsstelle QM + Krankenhausleitung) und QM-Arbeitskreis (Stabsstelle QM + interdisziplinäre Teilnehmende)
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available VA Risikomanagement (D1015) (03.08.2023) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management VA Medizinisches Notfallkonzept (D3946) (18.02.2022) |
| RM05 |
Pain management VA Schmerztherapie (11.10.2021) |
| RM06 |
Fall prophylaxis VA Sturzprophylaxe (Expertenstandard) (10.09.2020) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) VA Dekubitusprophylaxe (Expertenstandard) (15.06.2020) |
| RM08 |
Regulated handling of custodial measures VA Richtlinie zur Fixierung eines Patienten (D1666); VA Anordnung besondere Schutz und Sicherungsmaßnahmen (D531) (13.10.2020) |
| RM09 |
Regulated handling of occurring malfunctions of devices VA Umgang mit Medizinprodukten (D2775) (25.10.2021) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM18 |
Discharge management VA Entlassmanagement (D788) (14.10.2021) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Etablierung: CIRS, Meinungsmanagement, Risikomanagement, medizinisches Notfallkonzept
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 03.08.2023 |
| 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: monatlich
| 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) |