Dealing with risks in patient care

Quality management

M.A. Yvonne Borgerding

Abteilung für Organisationsentwicklung und Qualitätsmanagement

Krankenhausstraße 13
49661 Cloppenburg

Phone: 04471 -16-2067
Mail: ed.gnutfits-ses@gnidregrob.ennovy

erweitertes Direktorium

Conference frequency: halbjährlich

Risk management

Yvonne Borgerding

Abteilung für Organisationsentwicklung und Qualitätsmanagement

Krankenhausstraße 13
49661 Cloppenburg

Phone: 04471 -16-2067
Mail: ed.gnutfits-ses@gnidregrob.ennovy

erweitertes Direktorium

Conference frequency: halbjährlich

Risk management instruments and measures

No. Explanation
RM01

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

QM-Handbuch (16.02.2023)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

QM-Handbuch (16.02.2023)

RM05

Pain management

QM-Handbuch (16.02.2023)

RM06

Fall prophylaxis

QM-Handbuch (16.02.2023)

RM07

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

QM-Handbuch (16.02.2023)

RM08

Regulated handling of custodial measures

QM-Handbuch (16.02.2023)

RM09

Regulated handling of occurring malfunctions of devices

QM-Handbuch (16.02.2023)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Pathologiebesprechungen
  • Palliativbesprechungen
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 (16.02.2023)

RM15

Preoperative, complete presentation of necessary findings

QM-Handbuch (16.02.2023)

RM16

Procedure to avoid procedural and patient mix-ups

QM-Handbuch (16.02.2023)

RM17

Standards for recovery and postoperative care

QM-Handbuch (16.02.2023)

RM18

Discharge management

QM-Handbuch (16.02.2023)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Dokumentation im Maßnahmenplan

No. Explanation
IF01

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

As of: 29.03.2023

IF02

Internal evaluation of the received reports

taken monatlich

Conference committee

Conference frequency: andere Frequenz

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)