Dealing with risks in patient care

Quality management

Mirko Hersemann

Qualitätsmanagementbeauftragter

Hans-Nolte-Str. 1
32429 Minden

Phone: 0571 -790-2063
Mail: ed.nekinilksierknelheum@nnamesreh.okrim

Strategiekonferenz

Conference frequency: wöchentlich

Risk management

Mirko Hersemann

Qualitätsmanagementbeauftragter

Phone: 0571 -790-2063
Mail: ed.nekinilksierknelheum@nnamesreh.okrim

Strategiekonferenz

Conference frequency: wöchentlich

Risk management instruments and measures

No. Explanation
RM01

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

MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018)

RM02

Regular further education and training measures

RM04

Clinical emergency management

MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018)

RM05

Pain management

MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018)

RM06

Fall prophylaxis

MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018)

RM07

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

MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018)

RM08

Regulated handling of custodial measures

MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018)

RM09

Regulated handling of occurring malfunctions of devices

MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Pathologiebesprechungen
  • Palliativbesprechungen
  • Qualitätszirkel
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

MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018)

RM15

Preoperative, complete presentation of necessary findings

MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018)

RM16

Procedure to avoid procedural and patient mix-ups

MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018)

RM17

Standards for recovery and postoperative care

MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018)

RM18

Discharge management

MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018)

Fault reporting systems

Conference committee

Conference frequency: bei Bedarf

Measures

Einsatz von Patientenarmbändern, Qualitätszirkel, MRSA/MRE Screening, Begehungen (Hygiene, Arbeitsschutz, Brandschutz), Morbiditäts- und Mortalitätskonferenzen, Sturzprophylaxe, Dekubitusprophylaxe, Audits, Risikoanalysen, Befragungen (Einweiser, Patienten), Beschwerdemanagement

No. Explanation
IF01

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

As of: 01.03.2017

IF02

Internal evaluation of the received reports

taken bei Bedarf

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)

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