Dealing with risks in patient care
Quality management
Dipl.-Psych. Fabian Mundt
Leiter Organisationsentwicklung
Beurhausstraße 40
44137 Dortmund
Phone:
0231
-953-21070
Mail:
ed.odmukinilk@tdnum.naibaf
Qualitätsmanagement Projektmanagement Risikomanagement CIRS
Conference frequency: wöchentlich
Risk management
Ksenja Wittemeier
CIRS-Koordinatorin
Beurhausstraße 40
44137 Dortmund
Phone:
0231
-953-21073
Fax: 0231-953-20097
Mail:
ed.odmukinilk@reiemettiw.ajnesk
Ksenja Wittemeier
CIRS-Koordinatorin
Beurhausstraße 40
44137 Dortmund
Phone:
0231
-953-21073
Fax: 0231-953-20097
Mail:
ed.odmukinilk@reiemettiw.ajnesk
Der Arbeitskreis CIRS setzt sich aus Mitarbeitern/Mitarbeiterinnen aus dem ärztlichen wie pflegerischen Dienst zusammen. Es sind sowohl chirurgische als auch internistische Fächer vertreten. Ebenso ist der Bereich der Kinderheilkunde eingebunden. Geleitet wird der AK durch das QM
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Nexus Curator (25.10.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Nexus Curator (25.10.2023) |
| RM05 |
Pain management Nexus Curator (25.10.2023) |
| RM06 |
Fall prophylaxis Nexus Curator (25.10.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Nexus Curator (25.10.2023) |
| RM08 |
Regulated handling of custodial measures Nexus Curator (25.10.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Nexus Curator (25.10.2023) |
| 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 Nexus Curator (25.10.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings Nexus Curator (25.10.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Nexus Curator (25.10.2023) |
| RM17 |
Standards for recovery and postoperative care Nexus Curator (25.10.2023) |
| RM18 |
Discharge management Nexus Curator (25.10.2023) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
- Verbesserung der präoperativen Prozesse zur OP-Seitenmarkierung - Verbesserung des Medikamtionsprozesses zur Vermeidung von Medikamentenverwechselungen bei nicht benötigten Medikamenten in der Narkoseeinleitung
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 26.07.2023 |
| 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 |
|---|---|
| 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 |