Dealing with risks in patient care
Quality management
Frau Susanne Schött
Stabsstelle Projekt- und Qualitätsmanagement
Goethestraße 19
58239 Schwerte
Phone:
02304
-109-1295
Mail:
ed.hk-neiram@tteohcs.s
Geschäftsleitung Qualitätsmanagement
Conference frequency: quartalsweise
Risk management
Monika Hilsmann
Geschäftsleitung
58239 Schwerte
Phone:
02304
-109-217
Fax: 02304-109-207
Mail:
ed.hk-neiram@nnamslih.m
Geschäftsleitung Qualitätsmanagement
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikomanagement- Konzept (20.12.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Risikomanagement- Konzept (20.12.2022) |
| RM05 |
Pain management Qualitätsmanagement- Handbuch, Schmerzkonzept (04.08.2023) |
| RM06 |
Fall prophylaxis Qualitätsmanagement- Handbuch (10.01.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Qualitätsmanagement- Handbuch (25.05.2023) |
| RM08 |
Regulated handling of custodial measures Qualitätsmanagementhandbuch (28.08.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Risikomanagement- Konzept (20.12.2022) |
| 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 Teil der Dokumentation im Qualiutätsmanagement- Handbuch Hämotherapie (12.06.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings Qualitätsmanagementhandbuch (30.08.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Teil des Qualitätsmanagementhandbuchs (31.01.2023) |
| RM17 |
Standards for recovery and postoperative care Qualitätsmanagementhandbuch (18.08.2023) |
| RM18 |
Discharge management Teil des Qualitätsmanagement- Handbuchs (04.05.2023) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Seit dem Jahr 2007 ist eine CIRS Arbeitsgruppe installiert. Die Gruppe ist interdisziplinär zusammengesetzt. Eingetroffene Meldungen werden analysiert, bewertet und Maßnahmen zur Verbesserung in dem jeweiligen Fachbereich angestoßen. Zusätzlich werden aufgearbeitete Fälle monatlich den Mitarbeitern zur Verfügung gestellt.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 06.09.2021 |
| IF02 |
Internal evaluation of the received reports taken monatlich |
| IF03 |
Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken quartalsweise |
Conference committee
Conference frequency: halbjährlich
| 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) |