Dealing with risks in patient care

Quality management

Godehard Winter

Leitbild- und Qualitätsmanagement-Beauftragter

Neustraße 1
59348 Lüdinghausen

Phone: 02591 -231-464
Mail: ed.nesuahgnideul-hms@retniw.drahedog

Direktorium, QM

Conference frequency: monatlich

Risk management

Godehard Winter

Leitbild- und Qualitätsmanagement-Beauftragter

Neustraße 1
59348 Lüdinghausen

Phone: 02591 -231-464
Fax: 2591-464-341
Mail: ed.nesuahgnideul-hms@retniw.drahedog

Direktorium, QM

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

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

Risikomanagement Konzept (06.12.2021)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Internes Notfallmanagement (05.04.2022)

RM05

Pain management

Handbuch Schmerztherapie (25.04.2018)

RM06

Fall prophylaxis

Sturzpropylaxe in der Pflege (15.05.2020)

RM07

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

Dekubitus-Prophylaxe (23.02.2023)

RM08

Regulated handling of custodial measures

Verfahrensanweisung Fixierung (18.09.2023)

RM09

Regulated handling of occurring malfunctions of devices

Produktrückruf - Produktmitteilung (10.12.2021)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Mortalitäts- und Morbiditätskonferenzen
  • Mikrobiologische Visiten
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

Bestandteil der OP-Checkliste (07.11.2018)

RM15

Preoperative, complete presentation of necessary findings

OP-Checkliste (07.11.2018)

RM16

Procedure to avoid procedural and patient mix-ups

Handbuch Chirurgie (25.06.2018)

RM17

Standards for recovery and postoperative care

?? (01.01.2022)

Fault reporting systems

Conference committee

Conference frequency: bei Bedarf

Measures

z. B. Schulungen zu Medikamentenanwendung, Fortbildungen zu Dekubitusprophylaxe und Harninkontinenz,

No. Explanation
IF01

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

As of: 06.10.2020

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 bei Bedarf

Conference committee

Conference frequency: quartalsweise

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