Dealing with risks in patient care
Quality management
Dr. rer. nat. Jochen Bauer
Leiter des Qualitätsmanagements
Nieheimer Str. 34
32839 Steinheim
Phone:
05272
-607-1271
Mail:
ed.ewhk@reuab.j
QM-relevante Themen werden im Rahmen der Betriebsleitungssitzungen (Geschäftsführung, Pflegedirektor, ärztl. Direktor, Allgemeine Verwaltung, QM, bei Bedarf Experten) beraten.
Conference frequency: monatlich
Risk management
Jochen Bauer
Leiter des Qualitätsmanagements
Nieheimer Str. 34
32839 Steinheim
Phone:
05272
-607-1271
Fax: 05272-607-1279
Mail:
ed.ewhk@reuab.j
QM-relevante Themen werden im Rahmen der Betriebsleitungssitzungen (Geschäftsführung, Pflegedirektor, ärztl. Direktor, Allgemeine Verwaltung, QM, bei Bedarf Experten) beraten.
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitätsmanagement-Handbuch im Intranet (ISO 9001:2015) (15.12.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Qualitätsmanagement-Handbuch im Intranet (ISO 9001:2015) (15.12.2023) |
| RM05 |
Pain management Qualitätsmanagement-Handbuch im Intranet (ISO 9001:2015) (15.12.2023) |
| RM06 |
Fall prophylaxis Qualitätsmanagement-Handbuch im Intranet (ISO 9001:2015) (15.12.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Qualitätsmanagement-Handbuch im Intranet (ISO 9001:2015) (15.12.2023) |
| RM08 |
Regulated handling of custodial measures Qualitätsmanagement-Handbuch im Intranet (ISO 9001:2015) (15.12.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Qualitätsmanagement-Handbuch im Intranet (ISO 9001:2015) (15.12.2023) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM13 |
Application of standardised surgical check lists |
| RM16 |
Procedure to avoid procedural and patient mix-ups Qualitätsmanagement-Handbuch im Intranet (ISO 9001:2015) (15.12.2023) |
| RM18 |
Discharge management Qualitätsmanagement-Handbuch im Intranet (ISO 9001:2015) (15.12.2023) |
Fault reporting systems
Conference committee
Conference frequency: wöchentlich
Measures
Einführung E-Learning, Umstrukturierung wg. Wegfall der Intensivstation, verbesserte Patientendokumentation, Behandlungsraum für Wundversorgung, Umsetzung Expertenstandard Ernährung
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 15.12.2023 |
| IF02 |
Internal evaluation of the received reports taken monatlich |
Conference committee
Conference frequency: quartalsweise
| No. | Explanation |
|---|---|
| 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) |