Dealing with risks in patient care
Quality management
Jens Lammers
Leiter Referat Qualitäts- & klinisches Risikomanagement
Rintelner Straße 85
32657 Lemgo
Phone:
05231
-725026-
Mail:
ed.eppil-mukinilk@ofni
Geschäftsführung, Referat Qualitäts- & klinisches Risikomanagement, Pflegedirektion, Medizin-Controlling, Personal-Controlling, Personalmanagement, Abteilungsleitungen
Conference frequency: quartalsweise
Risk management
Jens Lammers
Leiter Referat Qualitäts- & klinisches Risikomanagement
Phone:
05231
-725026-
Mail:
ed.eppil-mukinilk@ofni
Geschäftsführung, Referat Qualitäts- & klinisches Risikomanagement, Pflegedirektion, Medizin-Controlling, Personal-Controlling, Personalmanagement, Abteilungsleitungen
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitäts- u. klinisches Risikomanagement Handbuch "Zentrale Prozesse" Version 20.0 (15.05.2024) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Qualitäts- u. klinisches Risikomanagement Handbuch "Zentrale Prozesse" (15.05.2024) |
| RM05 |
Pain management Qualitäts- u. klinisches Risikomanagement Handbuch "Zentrale Prozesse" Version 20.0 (15.05.2024) |
| RM06 |
Fall prophylaxis QM-VA-P-02-Sturzprophylaxe (09.09.2024) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) QM-VA-P-01 Dekubitusprophylaxe (12.07.2024) |
| RM08 |
Regulated handling of custodial measures QM-VA_MP11_Freiheitsentziehende Maßnahmen (30.08.2024) |
| RM09 |
Regulated handling of occurring malfunctions of devices Qualitäts- u. klinisches Risikomanagement Handbuch "Zentrale Prozesse" (15.05.2024) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM13 |
Application of standardised surgical check lists |
| RM15 |
Preoperative, complete presentation of necessary findings QM_VA_MP14_Patientensicherheit u. OP-Checkliste (27.06.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups QM_VA_MP13_Team-TimeOut u. ZählkontrollenQM_VA_MP14_PatientensicherheitQM_VA_MP16_Patienten-ID-Bänder (03.11.2023) |
| RM17 |
Standards for recovery and postoperative care Qualitäts- u. klinisches Risikomanagement Handbuch "Zentrale Prozesse" Version 20 (15.05.2024) |
| RM18 |
Discharge management Qualitäts- u. klinisches Risikomanagement Handbuch "Zentrale Prozesse" Version 20 (15.05.2024) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
z. B.: SOP zur Vermeidung von Seitenverwechselungen, Überarbeitung von OP-Checklisten, Patientenidentifikationsbändern; standardisierte Etikettierung von Spritzen; gesonderte Applikations-Systeme zur Vermeidung von Verwechselungen bei der enteralen bzw. parenteralen Medikamentengabe.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 10.06.2024 |
| 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 |
|---|---|
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |
| 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) |