Dealing with risks in patient care
Quality management
Shirley Rasche
Qualitäts- und Risikomanagement
Bürkle-de-la-Camp-Platz 1
44789 Bochum
Phone:
0234
-302-6118
Mail:
ed.liehsnnamgreb@ehcsar.yelrihs
Geschäftsführung/ Verwaltungsdirektorin, Pflegedirektion, Ärztliche Direktion, Leiter Medizinmanagement , Qualitäts- und Risikomanagement
Conference frequency: jährlich
Risk management
Shirley Rasche
Qualitäts- und Risikomanagement
44702 Bochum
Phone:
0234
-302-6118
Mail:
ed.liehsnnamgreb@ehcsar.yelrihs
Geschäftsführung/ Verwaltungsdirektorin, Pflegedirektion, Ärztliche Direktion, Leiter Medizinmanagement , Qualitäts- und Risikomanagement
Conference frequency: jährlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Jahres CIRS-Auswertung (02.10.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Notfallmanagement (02.10.2023) |
| RM05 |
Pain management Handbuch Akutschmerztherapie (02.10.2023) |
| RM06 |
Fall prophylaxis klinikbezogene Umsetzung des Expertenstandards Sturzprophylaxe (02.10.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) klinikinterne Umsetzung des Expertenstandards Dekubitusprophylaxe (02.10.2023) |
| RM08 |
Regulated handling of custodial measures Erstellung VA freiheitsentziehende Maßnahmen (02.10.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Ausfallkonzepte (02.10.2023) |
| 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 Jahres CIRS-Auswertung (02.10.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings OP-Sicherheitscheckliste (02.10.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups OP-Sicherheitscheckliste (02.10.2023) |
| RM17 |
Standards for recovery and postoperative care OP-Sicherheitscheckliste (02.10.2023) |
| RM18 |
Discharge management VA Entlassmanagement (02.10.2023) |
Fault reporting systems
Conference committee
Conference frequency: andere Frequenz
Measures
Bereichs- sowie prozessorientierte Risikoanalysen Checkliste „Klinisches Risikomanagement und Patientensicherheit Crew Ressource Management / Simulationen Handlungsempfehlungen M&M-Konferenzen Fallanalysen Beschwerdemanagement Critical Incident Reporting System
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.12.2006 |
| 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: andere Frequenz
| 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) |
| EF02 |
CIRS Berlin (Medical Association Berlin, 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 |