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Marien-Hospital Wattenscheid

Dealing with risks in patient care

Quality management

Responsible person

Dr. Andreas Hellwig

Geschäftsbereichsleiter Medizinmanagement

Parkstraße 15
44866 Bochum

Phone: 0234 -509-8899
Mail: ed.oblkk@mq

Steering committee

Alle klinischen und betrieblichen Fachabteilungen.

Conference frequency: halbjährlich

Risk management

Responsible person

Andreas Hellwig

Geschäftsbereichsleiter Medizinmanagement

Parkstraße 15
44866 Bochum

Phone: 0234 -509-8899
Mail: ed.oblkk@mq

Steering committee

Geschäftsbereichsleiter Risikomanagement / Risikomanagementhauptverantwortlicher KKB / Qualitätsmanager, betrieblicher und klinischer Risikomanager inkl. Stellvertreter, Informationssicherheits-Risikomanagerin

Conference frequency: quartalsweise

Risk management instruments and measures

Instruments and measures

No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Managementhandbuch (31.05.2022)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Managementhandbuch (17.07.2018)
RM05	Pain management Managementhandbuch (28.01.2022)
RM06	Fall prophylaxis Managementhandbuch (14.04.2020)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Managementhandbuch (30.04.2021)
RM08	Regulated handling of custodial measures Managementhandbuch (23.05.2023)
RM09	Regulated handling of occurring malfunctions of devices Managementhandbuch (02.06.2023)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Pathologiebesprechungen Palliativbesprechungen Radiologiebesprechungen GERD-Teamsitzungen
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 Managementhandbuch (31.08.2022)
RM15	Preoperative, complete presentation of necessary findings Managementhandbuch (31.08.2022)
RM16	Procedure to avoid procedural and patient mix-ups Managementhandbuch (21.12.2020)
RM17	Standards for recovery and postoperative care Vitalcheck Pflege (29.10.2020)
RM18	Discharge management Managementhandbuch (31.08.2022)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

CIRS Gremium, Gremium Sicherheit im KKB, Einführung neuer Checklisten, kontinuierliche Weiterentwicklung von Standrads, Konzepten (z. B. zentrales Schadenmanagement), Verfahrensanweisungen etc.

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 06.03.2020
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 monatlich

No.

Explanation

IF01

Documentation and procedural instructions for handling the error reporting system are available

As of: 06.03.2020

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 monatlich

Across all institutions

Conference committee

Conference frequency: quartalsweise

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)