Dealing with risks in patient care
Quality management
Katrin Stapenhorst
Leiterin Abteilung Qualitätsmanagement ab 01.01.2023
Vollenstraße 10
48249 Dülmen
Phone:
02541
-8914123-
Mail:
ed.dlefseoc-ctc@tsrohnepats.nirtak
Katrin Stapenhorst
Leiterin Abteilung Qualitätsmanagement ab 01.01.2023
Vollenstraße 10
48249 Dülmen
Phone:
02541
-8914123-
Mail:
ed.dlefseoc-ctc@tsrohnepats.nirtak
Mitglieder der QM-Steuerungsgruppe: Krankenhausleitung der Christophorus Kliniken, Krankenhausleitung der Christophorus Klinik am Schlossgarten, Ltg. der Abt. QM nimmt grundsätzlich an den Sitzungen teil.
Conference frequency: quartalsweise
Risk management
Katrin Stapenhorst
Leiterin Abteilung Qualitätsmanagement ab 01.01.2023
Vollenstraße 10
48249 Dülmen
Phone:
02541
-8914123-
Mail:
ed.dlefseoc-ctc@tsrohnepats.nirtak
Katrin Stapenhorst
Leiterin Abteilung Qualitätsmanagement ab 01.01.2023
Vollenstraße 10
48249 Dülmen
Phone:
02541
-8914123-
Mail:
ed.dlefseoc-ctc@tsrohnepats.nirtak
CIRS-Gruppe bestehend aus Mitarbeitenden der Medizin, Pflege, Technik, Qualitätsmanagement sowie die Steuerungsgruppe Qualitätsmanagement der Kliniken
Conference frequency: andere Frequenz
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Herzalarm am CK-Standort Dülmen (Ablauforganisation) (10.05.2023) |
| RM05 |
Pain management Handbuch Schmerztherapie in den Christophorus Kliniken (24.05.2023) |
| RM06 |
Fall prophylaxis Ablaufschema zur Sturzprophylaxe (15.02.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Ablaufschema zur Dekubitusprophylaxe (02.07.2021) |
| RM08 |
Regulated handling of custodial measures Fixierung/Freiheitsentziehende Maßnahmen (feM) beantragen und dokumentieren Fixierung/Freiheitsentziehende Maßnahmen (feM) durchführen (31.05.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Umsetzen des Medizinprodukterecht-Durchführungsgesetz - MPDG (17.08.2022) |
| 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 Perioperative Sicherheits-Checkliste (22.09.2020) |
| RM15 |
Preoperative, complete presentation of necessary findings Checkliste zur OP-Vorbereitung (29.10.2020) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Patientenarmband zur Identifikation Checkliste zur OP-Vorbereitung Patientenversorgung vor und im OP (OP-Vorbereitung) (13.04.2022) |
| RM17 |
Standards for recovery and postoperative care Aufgaben des Akut-Schmerz-Dienstes (08.06.2022) |
| RM18 |
Discharge management Entlassungsmanagement Checkliste Entlassungsmanagement (18.05.2021) |
Fault reporting systems
Conference committee
Conference frequency: andere Frequenz
Measures
z.B. verbesserte Warnmeldungen bei der Verordnung von Medikamenten
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 13.08.2021 |
| 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: andere Frequenz
| 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) |
| 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 |