Dealing with risks in patient care
Quality management
Lisa Ellebracht
Leitung Qualitätsmanagement
Wichernstraße 8
48147 Münster
Phone:
0251
-2706-30402
Mail:
ed.renaixela@thcarbelle.l
Kaufm. Direktor, Chefärzte, Pflegedirektion, Therapeutische Leitung, Qualitätsmanagement
Conference frequency: quartalsweise
Risk management
Kaufm. Direktor, Chefärzte, Pflegedirektion, Therapeutische Leitung, Qualitätsmanagement
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available "Qualitäts- und Risikomanagement am EVK" (Bestandteil des QM-Handbuchs) (12.12.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management "Hausinternes Notfallverfahren" (Bestandteil des QM-Handbuchs) (06.09.2022) |
| RM05 |
Pain management "Schmerzhandbuch" (Bestandteil des QM-Handbuchs) (20.06.2024) |
| RM06 |
Fall prophylaxis "Sturzprophylaxe" (Bestandteil des QM-Handbuchs) (08.03.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) "Dekubitusprophylaxe" (Bestandteil des QM-Handbuchs) (10.05.2021) |
| RM08 |
Regulated handling of custodial measures "Pflegestandard Freiheitsentziehende Maßnahmen" (Bestandteil des QM-Handbuchs) (18.07.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices "Lenkung fehlerhafter Produkte" (Bestandteil des QM-Handbuchs) (10.05.2021) |
| 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 "OP-Sicherheitscheckliste" (Bestandteil des QM-Handbuchs) (05.05.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings "OP-Sicherheitscheckliste" (Bestandteil des QM-Handbuchs) (05.05.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups "OP-Sicherheitscheckliste" (Bestandteil des QM-Handbuchs) (05.05.2021) |
| RM17 |
Standards for recovery and postoperative care "VA Aufwachraum" (Bestandteil des QM-Handbuchs) (20.02.2024) |
| RM18 |
Discharge management "DNQP Expertenstandard Entlassungsmanagement in der Pflege" (Bestandteil des QM-Handbuchs) (03.08.2023) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Umfangreiche Maßnahmenpakete zur Implementierung von Präventionsmaßnahmen und Sicherheitsbarrieren.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.06.2023 |
| 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 bei Bedarf |
Conference committee
Conference frequency: monatlich
| 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) |