Dealing with risks in patient care

Quality management

Eva Badinski

Leitung Qualitäts- und Risikomanagement

Jakobstr. 27-31
50678 Köln

Phone: 0221 -3308-5480
Mail: ed.nehcretseolksnireves@iksnidabe

Alle Bereiche

Conference frequency: bei Bedarf

Risk management

Eva Badinski

Leitung Qualitäts- und Risikomanagement

Phone: 0221 -3308-5480
Mail: ed.nehcretseolksnireves@iksnidabe

CIRS-Team aus Mitarbeitern der Ärzte, Pflegefachkräfte und Mitarbeitenden des Qualitäts- und Risikomanagements

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

QM/RM Dokumentation (15.11.2021)

RM02

Regular further education and training measures

RM04

Clinical emergency management

QM/RM Dokumentation (15.11.2021)

RM05

Pain management

QM/RM Dokumentation (15.11.2021)

RM06

Fall prophylaxis

QM/RM Dokumentation (15.11.2021)

RM07

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

QM/RM Dokumentation (15.11.2021)

RM08

Regulated handling of custodial measures

QM/RM Dokumentation (15.11.2021)

RM09

Regulated handling of occurring malfunctions of devices

QM/RM Dokumentation (15.11.2021)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Palliativbesprechungen
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

Name: Operative Sicherheitscheckliste (gem. WHO) (16.12.2022)

RM15

Preoperative, complete presentation of necessary findings

Name: Operative Sicherheitscheckliste (gem. WHO) (16.12.2022)

RM16

Procedure to avoid procedural and patient mix-ups

QM/RM Dokumentation und operative Sicherheitscheckliste (16.12.2022)

RM17

Standards for recovery and postoperative care

QM/RM Dokumentation (15.11.2021)

RM18

Discharge management

QM/RM Dokumentation (15.11.2021)

Fault reporting systems

Conference committee

Conference frequency: quartalsweise

Measures

Einleitung von Verbesserungsmaßnahmen durch das CIRS-Team beispielsweise in Form von Fortbildungen/Memoranden, Optimierung von Prozessbeschreibungen/Checklisten, Anschaffung von Hilfsmitteln

No. Explanation
IF01

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

As of: 11.02.2020

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: bei Bedarf

No. Explanation
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