Dealing with risks in patient care

Quality management

Alexandra West

Qualitätsmanagementbeauftragte

Orsoyer Str. 55
47495 Rheinberg

Phone: 02841 -107-13180
Mail: ed.sreom-fesoj-ts@tsew.ardnaxela

Betriebsleitung und direkte Anbindung der Leitung des Zentralen QM über monatliches JourFixe mit der Geschäftsführung.

Conference frequency: monatlich

Risk management

Alexandra West

Qualitätsmanagementbeauftragte

Phone: 02841 -107-13180
Fax: 02841-107-14301
Mail: ed.sreom-fesoj-ts@tsew.ardnaxela

Betriebsleitung und direkte Anbindung der Leitung des Zentralen QM über monatliches JourFixe mit der Geschäftsführung.

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

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

Organisationshandbuch (08.09.2022)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Organisationshandbuch (08.09.2022)

RM05

Pain management

Organisationshandbuch (08.09.2022)

RM06

Fall prophylaxis

Organisationshandbuch (08.09.2022)

RM07

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

Organisationshandbuch (08.09.2022)

RM08

Regulated handling of custodial measures

Organisationshandbuch (08.09.2022)

RM09

Regulated handling of occurring malfunctions of devices

Organisationshandbuch (08.09.2022)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Palliativbesprechungen
  • Qualitätszirkel
RM12

Use of standardised information sheets

RM16

Procedure to avoid procedural and patient mix-ups

Organisationshandbuch (08.09.2022)

RM18

Discharge management

Organisationshandbuch (08.09.2022)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Identifikationsarmband interne Audits Begehungen (Arbeitssicherheit) Hygienebegehungen Notfallmanagement / Intoxikation Reanimationsübungen Medikationskontrollen ABS Team Überarbeitung "Funkmanagement" Schulungen zum Patientenrechtegesetz Peer Reviews im Pflegedienst Fall- und Mortalitätsbesprechungen im ärztlichen Dienst

No. Explanation
IF01

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

As of: 10.06.2020

IF02

Internal evaluation of the received reports

taken jährlich

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)

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