Dealing with risks in patient care
Quality management
Dipl. Pädagogin Sabine Rautenberg
Leitung Zentrales Qualitätsmanagement
An der Rosenhöhe 27
33647 Bielefeld
Phone:
0521
-581-2580
Mail:
ed.dlefeleibmukinilk@grebnetuar.enibas
QM-Kommission: Geschäftsführer, Pflegedirektorin, Kaufm. Direktor, Chefärzte und Oberärzt*innen aus 6 Fachkliniken, zentrales Qualitätsmanagement, Betriebsrat. Die QM-Kommission steuert alle qm-relevanten Prozesse im Klinikum Bielefeld.
Conference frequency: quartalsweise
Risk management
Wolfgang Schmidt-Barzynski
Ärztlicher Direktor
33526 Bielefeld
Phone:
0521
-943-8701
Fax: 0521-943-8799
Mail:
ed.dlefeleibmukinilk@ofni
Steuerungsgruppe klinisches Risikomanagement: Vorsitz: Ärztlicher Direktor, Mitglieder aus Hochrisikobereichen, Zentrales QM, Betriebsrat, standort-und berufsgruppenübergreifend. Die Steuerungsgruppe ist verantwortlich für die Umsetzung der g-BA QMRL sowie für die Umsetzung der eigenen Vorgaben.
Conference frequency: halbjährlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM-Handbuch (08.08.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management QM-Handbuch (08.08.2022) |
| RM05 |
Pain management QM-Handbuch (08.08.2022) |
| RM06 |
Fall prophylaxis QM-Handbuch (08.08.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) QM-Handbuch (08.08.2022) |
| RM08 |
Regulated handling of custodial measures QM-Handbuch (08.08.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices QM-Handbuch (08.08.2022) |
| 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 QM-Handbuch (08.08.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings QM-Handbuch (08.08.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups QM-Handbuch (08.08.2022) |
| RM17 |
Standards for recovery and postoperative care QM-Handbuch (08.08.2022) |
| RM18 |
Discharge management QM-Handbuch (08.08.2022) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Einführung und Evaluierung der Umsetzung von Sicherheitschecklisten im OP, Endoskopie, HKL etc., Einführung von Patientenarmbändern, Maßnahmen zum Medikamentenmanagement, internes CIRS, M+M-Konferenzen
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 08.08.2022 |
| IF02 |
Internal evaluation of the received reports taken quartalsweise |
| IF03 |
Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken halbjährlich |
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 |