Dealing with risks in patient care

Quality management

Herr Dirk Tedeschi

Leitung Qualitätsmanagement

Kiskerstr. 26
33615 Bielefeld

Phone: 0521 -589-9010
Mail: ed.dlefeleib-ohk@ihcsedet.krid

Geschäftsführung, Qualitätsmanagement, Personalabteilung, Kaufmännische Leitung Zu spezifischen Themen werden weitere Personen gezielt eingeladen.

Conference frequency: quartalsweise

Risk management

Dirk Tedeschi

Leitung Qualitätsmanagement

Kiskerstrasse 26 26
33615 Bielefeld

Phone: 0521 -589-9010
Fax: 0521-589-9004
Mail: ed.dlefeleib-ohk@ihcsedet.krid

Geschäftsführung, Qualitätsmanagement, Ärztliche Direktoren, Pflegedienstleitung, Kaufmännische Leitung

Conference frequency: jährlich

Risk management instruments and measures

No. Explanation
RM01

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

Name: Open-cms, webbasiertes Intranet (04.10.2023)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Name: Open-cms, webbasiertes Intranet (04.10.2023)

RM05

Pain management

Name: Open-cms, webbasiertes Intranet (04.10.2023)

RM06

Fall prophylaxis

Name: Open-cms, webbasiertes Intranet (04.10.2023)

RM07

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

Name: Open-cms, webbasiertes Intranet (04.10.2023)

RM08

Regulated handling of custodial measures

Name: Open-cms, webbasiertes Intranet (04.10.2023)

RM09

Regulated handling of occurring malfunctions of devices

Name: Open-cms, webbasiertes Intranet (04.10.2023)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Pathologiebesprechungen
  • Qualitätszirkel
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

Name: Open-cms, webbasiertes Intranet (04.10.2023)

RM15

Preoperative, complete presentation of necessary findings

Name: Open-cms, webbasiertes Intranet (04.10.2023)

RM16

Procedure to avoid procedural and patient mix-ups

Name: Open-cms, webbasiertes Intranet (04.10.2023)

RM17

Standards for recovery and postoperative care

Name: Open-cms, webbasiertes Intranet (04.10.2023)

RM18

Discharge management

Name: Open-cms, webbasiertes Intranet (04.10.2023)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Einführung der elektronischen Patientenakte

No. Explanation
IF01

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

As of: 29.05.2019

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 jährlich

Conference committee

Conference frequency: bei Bedarf

No. Explanation
EF06

CIRS NRW (North Rhine and Westphalia-Lippe Medical Chambers, North Rhine Westphalia Hospital Association, North Rhine and Westphalia-Lippe Association of Statutory Health Insurance Doctors, German Medical Association, National Association of Statutory Hea