Dealing with risks in patient care

Quality management

Christian Stienhans

Verwaltungsdirektor

Hindenburgstraße 56
32257 Bünde

Phone: 05223 -167-209
Mail: ed.suahneknark-sakul@ofni

QB des Hauses Assistentin der Geschäftsführung

Conference frequency: monatlich

Risk management

Christian Stienhans

Verwaltungsdirektor


32221 Bünde

Phone: 05223 -167-209
Fax: 05223-167-192
Mail: ed.suahneknark-sakul@ofni

QB des Hauses Assistentin der Geschäftsführung

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

Comprehensive quality and/or risk management documentation (QM/RM documentation) is available

Qualitätsmanagementhandbuch (30.01.2018)

RM02

Regular further education and training measures

RM04

Clinical emergency management

Qualitätsmanagementhandbuch (30.01.2018)

RM05

Pain management

Ärztliches und pflegerische Schmerzkonzepte (01.03.2021)

RM06

Fall prophylaxis

Sturzkonzept (17.01.2020)

RM07

Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”)

Standard 01 Dekubitusprophylaxe (24.02.2022)

RM08

Regulated handling of custodial measures

VA-Haus Nr.78 (16.03.2022)

RM09

Regulated handling of occurring malfunctions of devices

Qualitätsmanagementhandbuch (30.01.2018)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Palliativbesprechungen
  • Qualitätszirkel
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

Qualitätsmanagementhandbuch (30.01.2018)

RM15

Preoperative, complete presentation of necessary findings

Qualitätsmanagementhandbuch (30.01.2018)

RM16

Procedure to avoid procedural and patient mix-ups

VA-Haus Nr. 64 (30.08.2022)

RM17

Standards for recovery and postoperative care

Qualitätsmanagementhandbuch (30.01.2018)

RM18

Discharge management

Entlassungskonzept (16.03.2021)

Fault reporting systems

Conference committee

Conference frequency: halbjährlich

Measures

In unserer Einrichtung gibt es viele Maßnahmen, die der Verbesserung der Patientensicherheit dienen: a) OP-WHO-Checkliste, b) Behandlungspfade, c) Sturzprophylaxe, d) Umgang mit MRSA-Patienten, e) Arzneimitteltherapiesicherheit, f) Tragen von Patientenarmbändern und v.m.

No. Explanation
IF01

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

As of: 02.05.2019

IF02

Internal evaluation of the received reports

taken halbjährlich

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 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