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
Fax: 0234-302-6200
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 Konzept zur Umsetzung des Qualitäts- und Risikomanagements (01.11.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management VA Notfallmanagement (15.12.2023) |
| RM05 |
Pain management Handbuch Akutschmerztherapie (15.05.2023) |
| RM06 |
Fall prophylaxis Klinikbezogene Umsetzung des Expertenstandards Sturzprophylaxe (01.10.2023) |
| 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 (10.03.2023) |
| RM08 |
Regulated handling of custodial measures VA Freiheitsentziehende Maßnahmen (17.11.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Ausfallkonzepte (07.12.2023) |
| 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 Konzept zur Umsetzung des Qualitäts- und Risikomanagements (01.11.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings Konzept zur Umsetzung des Qualitäts- und Risikomanagements (01.11.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Konzept zur Umsetzung des Qualitäts- und Risikomanagements (01.11.2023) |
| RM17 |
Standards for recovery and postoperative care SOP AWR (28.09.2023) |
| RM18 |
Discharge management VA Entlassmanagement (02.10.2023) |
Fault reporting systems
Conference committee
Conference frequency: halbjährlich
Measures
Kontinuierliches Maßnahmenmanagement
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.03.2023 |
| 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: halbjährlich
| No. | Explanation |
|---|---|
| EF01 |
CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association) |
| EF02 |
CIRS Berlin (Berlin Medical Association, German Medical Association) |
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |
| EF06 |
CIRS NRW (North Rhine and Westphalia-Lippe Medical Associations, North Rhine-Westphalia Hospital Association, North Rhine and Westphalia-Lippe Associations of Statutory Health Insurance Physicians, German Medical Association) |