Dealing with risks in patient care

Quality management

Dr. Doris Kurscheid-Reich

Leitung Qualitätsmanagement, klinisches Risikomanagement und Beschwerdemanagement

Gotenstraße 1
42653 Solingen

Phone: 0212 -547-2694
Mail: ed.negnilosmukinilk@diehcsruk

Qualitätsmanagement Ärztlicher Dienst Pflegedienst Personalmanagement Medizincontrolling Krankenhaushygiene Betriebliches Gesundheitsmanagement Betriebsrat

Conference frequency: quartalsweise

Risk management

Doris Kurscheid-Reich

Leitung Qualitätsmanagement, klinisches Risikomanagement und Beschwerdemanagement

Phone: 0212 -547-2694
Fax: 0212-547-2130
Mail: ed.negnilosmukinilk@diehcsruk

Qualitätsmanagement Ärztlicher Dienst Pflegedienst Personalmanagement Medizincontrolling Krankenhaushygiene Betriebliches Gesundheitsmanagement Betriebsrat

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Verfahrensanweisung Reanimation (11.04.2023)

RM05

Pain management

QM-Handbuch Akutschmerztherapie (12.08.2022)

RM06

Fall prophylaxis

Arbeitsanweisung Sturzprophylaxe (01.03.2018)

RM07

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

Arbeitsanweisung Dekubitusprophylaxe (17.09.2018)

RM08

Regulated handling of custodial measures

Verfahrensanweisung Umgang mit freiheitsentziehenden Maßnahmen (01.03.2018)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Palliativbesprechungen
  • Qualitätszirkel
  • Andere
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

Verfahrensanweisung Anwendung der OP-Checkliste (15.08.2018)

RM15

Preoperative, complete presentation of necessary findings

Verfahrensanweisung Anwendung der OP-Checkliste (inkl. Team-Time-Out) (15.08.2018)

RM16

Procedure to avoid procedural and patient mix-ups

Verfahrensanweisung Sichere Patientenidentifikation (12.11.2018)

RM17

Standards for recovery and postoperative care

Arbeitsanweisung Aufwachraum (24.07.2023)

RM18

Discharge management

Verfahrensanweisung Interdisziplinäres Entlassungsmanagement (11.06.2021)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Patientenarmbänder Seitenmarkierung OP-Checkliste Team-Time-Out Einsatz besser unterscheidbarer Materialien

No. Explanation
IF01

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

As of: 25.08.2022

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 jährlich

Conference committee

Conference frequency: monatlich

No. Explanation
EF03

KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors)

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