Dealing with risks in patient care
Quality management
Dr. rer. nat. Jochen Bauer
Leiter des Qualitätsmanagements
Elmarstr. 38
33014 Bad Driburg
Phone:
05272
-607-1271
Mail:
ed.ewhk@reuab.j
QM-relevante Themen werden im Rahmen der Betriebsleitungssitzung (Geschäftsführung, Pflegedirektor, ärztl. Direktor, Allgemeine Verwaltung, QM, bei Bedarf Experten) beraten.
Conference frequency: monatlich
Risk management
Jochen Bauer
Leiter des Qualitätsmanagements
Elmarstr. 38
33014 Bad Driburg
Phone:
05272
-607-1271
Fax: 05272-607-1279
Mail:
ed.ewhk@reuab.j
QM-relevante Themen werden im Rahmen der Betriebsleitungssitzung (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 QM-Handbuch im Intranet (ISO 9001:2015) (09.12.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management QM-Handbuch im Intranet (ISO 9001:2015) (09.12.2022) |
| RM05 |
Pain management QM-Handbuch im Intranet (ISO 9001:2015) (09.12.2022) |
| RM06 |
Fall prophylaxis QM-Handbuch im Intranet (ISO 9001:2015) (09.12.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) QM-Handbuch im Intranet (ISO 9001:2015) (09.12.2022) |
| RM08 |
Regulated handling of custodial measures QM-Handbuch im Intranet (ISO 9001:2015) (09.12.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices QM-Handbuch im Intranet (ISO 9001:2015) (09.12.2022) |
| 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 QM-Handbuch im Intranet (ISO 9001:2015) (09.12.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings QM-Handbuch im Intranet (ISO 9001:2015) (09.12.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups QM-Handbuch im Intranet (ISO 9001:2015) (09.12.2022) |
| RM17 |
Standards for recovery and postoperative care QM-Handbuch im Intranet (ISO 9001:2015) (09.12.2022) |
| RM18 |
Discharge management QM-Handbuch im Intranet (ISO 9001:2015) (09.12.2022) |
Fault reporting systems
Conference committee
Conference frequency: wöchentlich
Measures
Anpassung Standorts / der Notaufnahme an die Unfallchirurgie, Verbesserung der OP-Checkliste, Antibiotic Stewardship; Personal-Notsignalanlage Psychiatrie / Deeskalationstrainings,
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 09.12.2022 |
| 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 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 |