Dealing with risks in patient care
Quality management
Christina Salditt
Qualitäts- und Risikomanagement
Dünner Straße 214-216
41066 Mönchengladbach
Phone:
02161
-668-2195
Mail:
ed.krewuen-hk@ttidlas.c
interdisziplinär
Conference frequency: monatlich
Risk management
Christina Salditt (zertifizierte Risikomanagerin nach der ONR 49003)
Qualitäts- und Risikomanagement
Phone:
02161
-668-2195
Mail:
ed.krewuen-hk@ttidlas.c
Im Rahmen des Risikomanagementprozesses werden Risiken gemäß der ONR 49000 identifiziert und mit Risikoeigner und Mitarbeiter der betroffenen Bereiche analysiert, bewertet und Maßnahmen abgleitet. Zentral trifft sich monatlich eine interdisziplinäre Steuerungsgruppe zum Thema Risikomanagement
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM-Handbuch, Leitlinie klinisches Risikomanagement (22.08.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management QM-Handbuch, Leitlinie klinisches Risikomanagement (22.08.2023) |
| RM05 |
Pain management QM-Handbuch, Leitlinie klinisches Risikomanagement (22.08.2023) |
| RM06 |
Fall prophylaxis QM-Handbuch, Leitlinie klinisches Risikomanagement (22.08.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) QM-Handbuch, Leitlinie klinisches Risikomanagement (22.08.2023) |
| RM08 |
Regulated handling of custodial measures QM-Handbuch, Leitlinie klinisches Risikomanagement (22.08.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices QM-Handbuch, Leitlinie klinisches Risikomanagement (22.08.2023) |
| 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 QM-Handbuch, Leitlinie klinisches Risikomanagement (22.08.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings QM-Handbuch, Leitlinie klinisches Risikomanagement (22.08.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups QM-Handbuch, Leitlinie klinisches Risikomanagement (22.08.2023) |
| RM17 |
Standards for recovery and postoperative care QM-Handbuch, Leitlinie klinisches Risikomanagement (22.08.2023) |
| RM18 |
Discharge management QM-Handbuch, Leitlinie klinisches Risikomanagement (22.08.2023) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Risiko-Screenings durch den Versicherer, Patientenidentifikationsarmband, OP-Checkliste nach der WHO, CIRS, Risiko-Szenario-Analysen, Audits, Begehungen, M&M-Konferenzen, Apothekenvisiten, Reanimationskonzept, Maßnahmen zur AMTS, Teilnahme IQM, Bearbeitung der Never-Events, Durchführung von Simulationstrainings in der Geburtshilfe und ZNA, Teilnahme am Aktionstag zur Patientensicherheit mit Implementierung eines "Room of Error"
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 06.08.2022 |
| IF02 |
Internal evaluation of the received reports taken monatlich |
| IF03 |
Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken bei Bedarf |
Conference committee
Conference frequency: monatlich
| 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) |
| 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 |