Dealing with risks in patient care

Quality management

Inna Rifert

Leitung Regionalbereich Qualitätsmanagement

Marienstraße 2
34431 Marsberg

Phone: 05251 -702-2250
Mail: ed.eppurgtbb@trefir.i

Medizin, Pflege

Conference frequency: halbjährlich

Risk management

Inna Rifert

Leitung Regionalbereich Qualitätsmanagement

Marienstraße 2
34431 Marsberg

Phone: 05251 -702-2250
Mail: ed.eppurgtbb@trefir.i

Medizin, Pflege

Conference frequency: halbjährlich

Risk management instruments and measures

No. Explanation
RM01

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

Digitales QM-Handbuch (31.12.2022)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Digitales QM-Handbuch (31.12.2022)

RM05

Pain management

Digitales QM-Handbuch (31.12.2022)

RM06

Fall prophylaxis

Digitales QM-Handbuch (31.12.2022)

RM07

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

Digitales QM-Handbuch (31.12.2022)

RM08

Regulated handling of custodial measures

Digitales QM-Handbuch (31.12.2022)

RM09

Regulated handling of occurring malfunctions of devices

Digitales QM-Handbuch (31.12.2022)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Pathologiebesprechungen
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

Digitales QM-Handbuch (31.12.2022)

RM15

Preoperative, complete presentation of necessary findings

Digitales QM-Handbuch (31.12.2022)

RM16

Procedure to avoid procedural and patient mix-ups

Digitales QM-Handbuch (31.12.2022)

RM17

Standards for recovery and postoperative care

Digitales QM-Handbuch (31.12.2022)

RM18

Discharge management

Digitales QM-Handbuch (31.12.2022)

Fault reporting systems

Conference committee

Conference frequency: quartalsweise

Measures

WHO Checkliste

No. Explanation
IF01

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

As of: 31.10.2024

IF02

Internal evaluation of the received reports

taken halbjährlich

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: bei Bedarf

No. Explanation
EF03

KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association)

EF06

CIRS NRW (North Rhine and Westphalia-Lippe Medical Associations, North Rhine-Westphalia Hospital Association, North Rhine and Westphalia-Lippe Associations of Statutory Health Insurance Physicians, German Medical Association)