Dealing with risks in patient care
Quality management
Helene Grad
Leitung des Geschäftsbereiches ZQRM
Domagkstr. 5
48149 Münster
Phone:
0251
-83-52028
Mail:
ed.retsneumku@mrqz
QM Jour Fixe zwischen Geschäftsbereichsleitung Zentrales Qualitäts- u. klinisches Risikomanagement, dem ärztlichen Direktor und dem Pflegedirektor
Conference frequency: monatlich
Risk management
Helene Grad
Leitung des Geschäftsbereiches ZQRM
Domagkstr. 5
48149 Münster
Phone:
0251
-83-52028
Fax: 0251-83-54017
Mail:
ed.retsneumku@mrqz
Das Lenkungsgremium zum Risikomanagement (RM) ist im Gesamtvorstand angesiedelt. Die Inhalte hierfür werden in regelmäßigen Jour Fixen vorbereitet (Teilnehmer: Risikomanger aus dem klinischen und betriebswirtschaftlichen Bereich sowie IT Sicherheit und Compliancebereich).
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM-Plattform Nexus Curator (22.07.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management QM-Plattform Nexus Curator (29.08.2023) |
| RM05 |
Pain management QM-Plattform Nexus Curator (01.03.2022) |
| RM06 |
Fall prophylaxis QM-Plattform Nexus Curator (30.12.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) QM-Plattform Nexus Curator (23.10.2023) |
| RM08 |
Regulated handling of custodial measures QM-Plattform Nexus Curator (30.11.2018) |
| RM09 |
Regulated handling of occurring malfunctions of devices QM-Plattform Nexus Curator (29.08.2023) |
| 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-Plattform Nexus Curator (22.07.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings QM-Plattform Nexus Curator (22.07.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups QM-Plattform Nexus Curator (22.07.2022) |
| RM17 |
Standards for recovery and postoperative care QM-Plattform Nexus Curator (22.07.2022) |
| RM18 |
Discharge management QM-Plattform Nexus Curator (21.03.2022) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Ziel ist die Erhöhung der Patientensicherheit. Durch eine frühzeitige Identifikation von möglichen Fehlerquellen und Einleitung von Maßnahmen sollen Schäden oder Behandlungsfehler vermieden werden.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 12.10.2022 |
| 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: jährlich
| No. | Explanation |
|---|---|
| EF01 |
CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association, National Association of Statutory Health Insurance Doctors) |
| EF14 |
CIRS Health Care |