Dealing with risks in patient care
Quality management
Ulrike Hey
Leitung Qualitäts- und Risikomanagement
Barbarastraße 1
45964 Gladbeck
Phone:
0209
-172-53183
Mail:
ue.sunitsugua-ts@yeH.U
Anstelle eines Lenkungsgremiums finden monatliche Regelbesprechungen mit der Krankenhausdirektion und der Geschäftsführung statt.
Conference frequency: monatlich
Risk management
Ulrike Hey
Leitung Qualitäts- und Risikomanagement
Barbarastraße 1
45964 Gladbeck
Phone:
0209
-172-53183
Fax: 0209-172-3199
Mail:
ue.sunitsugua-ts@yeH.U
Geschäftsführung, Krankenhausdirektoren, Pflegedirektorinnen, Ärztliche Direktoren, Interner Revisor, Qualitäts- und Risikomanagement, Justitiar, Leiter Finanzbuchhaltung/Rechnungswesen/Controlling
Conference frequency: jährlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikobericht, Qualitätssystem (30.06.2021) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Prozessdokumentation (03.06.2022) |
| RM05 |
Pain management Postoperative Schmerztherapie (01.10.2021) |
| RM06 |
Fall prophylaxis Umsetzung des Expertenstandards Sturzprophylaxe (07.06.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Umsetzung des Expertenstandards Dekubitusprophylaxe (20.05.2022) |
| RM08 |
Regulated handling of custodial measures Fixierungsanordnung (01.10.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices Organisationshandbuch Medizintechnik (07.06.2023) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| 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 Dokumentation, VA Perioperatives Management (21.09.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings abteilungsspezifische Standards (10.06.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups OP-Sicherheitscheckliste (23.08.2023) |
| RM17 |
Standards for recovery and postoperative care Prozessbeschreibung (21.09.2022) |
| RM18 |
Discharge management Prozessbeschreibung Entlassmanagement (31.05.2022) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Optimierung innerklinisches Notfallmanagement.
| No. | Explanation |
|---|---|
| IF02 |
Internal evaluation of the received reports taken bei Bedarf |
Conference committee
Conference frequency: quartalsweise
| No. | Explanation |
|---|---|
|
Other |
|
| 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 |