Dealing with risks in patient care
Quality management
Susanne Hinzen
Leitung Qualitätsmanagement
Grünstr. 35
58095 Hagen
Phone:
02331
-201-6016
Mail:
ed.noiselpaga@hka.mq
Geschäftsführer, Pflegedirektorin, Verwaltungsdirektorin, Personalleiterin, Ärztlicher Direktor, Stv. Ärztlicher Direktor
Conference frequency: monatlich
Risk management
Susanne Hinzen
Leitung Qualitätsmanagement
Phone:
02331
-201-6016
Fax: 02331-201-1002
Mail:
ed.noiselpaga@hka.mq
1. QM-Team (Interdisziplinäre Arbeitsgruppe, in der u.a. CIRS-Fälle bearbeitet werden.) 2. AGAPLESION Lenkungsgruppe RM (2x jährlich) mit GFs, ZD Interne Revision und Compliance, ZD PQM, ZD Medizinmanagement, Kompetenzzentrum Wohnen & Pflegen: Konzernweite Analyse / Weiterentwicklung des RM
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risiko- und Managementbewertung (12.06.2019) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Umgang mit medizinischen Notfällen (18.04.2011) |
| RM05 |
Pain management Schmerzkonzept Notfallversorgung (10.01.2015) |
| RM06 |
Fall prophylaxis Sturzprophylaxe (19.06.2015) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Postoperative Überwachung (04.05.2015) |
| RM09 |
Regulated handling of occurring malfunctions of devices Risiko- und Managementbewertung (12.06.2019) |
| 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 Risiko- und Managementbewertung (12.06.2019) |
| RM15 |
Preoperative, complete presentation of necessary findings Risiko- und Managementbewertung (12.06.2019) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Risiko- und Managementbewertung (12.06.2019) |
| RM17 |
Standards for recovery and postoperative care Postoperative Überwachung (04.05.2015) |
| RM18 |
Discharge management Risiko- und Managementbewertung (12.06.2019) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
• Patientenidentifikationsarmbänder • Critical Incident Reporting System (CIRS) • Normierte Spritzenaufkleber • Sicherheitscheckliste (Risk List) • Medikationssicherheit • Hygienekonzeption
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.02.2019 |
| 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 monatlich |
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 |