Dealing with risks in patient care
Quality management
Diplom Pflegewirtin Christina Mersmann
Qualitätsmanagement
Lindenstraße 29
48286 Greven
Phone:
02571
-502-16004
Mail:
ed.neverg-hjm@nnamsrem.anitsirhc
Stiftungsebene: mind. 6x jährlich Treffen aller QM- und Leitbildbeauftragten der Stiftungshäuser. Festlegung der stiftungsübergreifenden Qualitätsstrategie Hausebene: 6x jährlich Treffen. Transfer der Stiftungsstrategie; Teilnehmer sind das Direktorium und Vertreter verschiedener Berufsgruppen
Conference frequency: andere Frequenz
Risk management
Christina Mersmann
Qualitätsmanagement
Lindenstraße 29
48268 Greven
Phone:
02571
-502-16004
Fax: 02571-502-16099
Mail:
ed.neverg-hjm@nnamsrem.anitsirhc
Steuerungsgruppe; Treffen finden ca. alle 5-6 Wochen statt.
Conference frequency: andere Frequenz
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitäts- und Risikomanagement-Konzept der St. Franziskus-Stiftung (06.12.2021) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Verfahrensanweisung innerklinische medizinische Notfälle (27.03.2023) |
| RM05 |
Pain management Verfahrensanweisung Schmerztherapie (15.03.2023) |
| RM06 |
Fall prophylaxis Sturzprophylaxe in der Pflege (08.11.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Standard Dekubitusprophylaxe (08.11.2022) |
| RM08 |
Regulated handling of custodial measures Freiheitsentziehende Maßnahmen (15.06.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices VA Umgang mit Medizinprodukten (24.05.2022) |
| 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 VA 11 Patient Blood Management / Patientenorientiertes Blutmanagement (15.03.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings VA Perioperative Patientensicherheit (20.07.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups VA Perioperative Patientensicherheit (20.07.2023) |
| RM17 |
Standards for recovery and postoperative care Postoperativer Versorgungsstandard (07.01.2022) |
| RM18 |
Discharge management Ablaufbeschreibung Entlassmanagement (07.07.2022) |
Fault reporting systems
Conference committee
Conference frequency: andere Frequenz
Measures
EDV-basiertes Fehlermeldesystem mit sofortiger Möglichkeit zur Bewertung des Risikos. Etablierung einer Steuerungsgruppe, die Fehler und Beinahefehler systematisch analysiert und Maßnahmen zur Vermeidung bzw. Risikominimierung empfiehlt.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 06.12.2022 |
| 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 jährlich |
Conference committee
Conference frequency: bei Bedarf
| 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 |
| EF14 |
CIRS Health Care |