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.
| 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 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 |