Dealing with risks in patient care

Quality management

Nicole Hages

Qualitätsmanagement-Beauftragte

Am Kokturkanal 2
32545 Bad Oeynhausen

Phone: 05731 -247-2640
Mail: ed.nekinilksierknelheum@segah.elocin

Geschäftsführung, Chefärzte Pflegedienstleitung, Betriebsrat, QMB

Conference frequency: bei Bedarf

Risk management

Uwe Frederking

Qualitätsmanagement-Beauftragter

Phone: 05731 -247-0
Fax: 05731-247-156
Mail: ed.nekinilksierknelheum@gnikrederf.ewu

Uwe Frederking

Qualitätsmanagement-Beauftragter

Phone: 05731 -247-0
Fax: 05731-247-156
Mail: ed.nekinilksierknelheum@gnikrederf.ewu

Geschäftsführung, Chefärzte, Pflegedienstleitung, Betriebsrat, QMB

Conference frequency: bei Bedarf

Risk management instruments and measures

No. Explanation
RM01

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

QM-Handbuch (16.04.2016)

RM02

Regular further education and training measures

RM04

Clinical emergency management

QM-Handbuch (16.04.2016)

RM05

Pain management

QM-Handbuch (16.04.2016)

RM06

Fall prophylaxis

QM-Handbuch (16.04.2016)

RM07

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

QM-Handbuch (16.04.2016)

RM08

Regulated handling of custodial measures

QM-Handbuch (16.04.2016)

RM09

Regulated handling of occurring malfunctions of devices

QM-Handbuch (16.04.2016)

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

QM-Handbuch (16.04.2016)

RM15

Preoperative, complete presentation of necessary findings

QM-Handbuch (16.04.2016)

RM16

Procedure to avoid procedural and patient mix-ups

QM-Handbuch (16.04.2016)

RM17

Standards for recovery and postoperative care

QM-Handbuch (16.04.2016)

RM18

Discharge management

QM-Handbuch (16.04.2016)

Fault reporting systems

Conference committee

Conference frequency: bei Bedarf

Measures

OP-Sicherheitscheckliste

No. Explanation
IF01

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

As of: 29.01.2015

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 halbjährlich

Conference committee

Conference frequency: bei Bedarf

No. Explanation
EF01

CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, 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