Dealing with risks in patient care
Quality management
Patrick Ruf
Leiter Qualitätsmanagement
Dr.-Krismann-Straße 12
33154 Salzkotten
Phone:
05251
-86-1416
Mail:
ed.znecniv@mq
interdisziplinäres Kernteam
Conference frequency: monatlich
Risk management
Geschäftsführung Ärztlicher Direktor Pflegedirektor Technischer Direktor
Conference frequency: bei Bedarf
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Zertifizierung der St. Vincenz-Krankenhaus GmbH nach DIN EN ISO 9001:2015 (24.04.2019) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Zertifizierung der St. Vincenz-Krankenhaus GmbH nach DIN EN ISO 9001:2015 (24.04.2019) |
| RM05 |
Pain management Zertifizierung der St. Vincenz-Krankenhaus GmbH nach DIN EN ISO 9001:2015 (24.04.2019) |
| RM06 |
Fall prophylaxis Zertifizierung der St. Vincenz-Krankenhaus GmbH nach DIN EN ISO 9001:2015 (24.04.2019) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Zertifizierung der St. Vincenz-Krankenhaus GmbH nach DIN EN ISO 9001:2015 (24.04.2019) |
| RM08 |
Regulated handling of custodial measures Zertifizierung der St. Vincenz-Krankenhaus GmbH nach DIN EN ISO 9001:2015 (24.04.2019) |
| RM09 |
Regulated handling of occurring malfunctions of devices Zertifizierung der St. Vincenz-Krankenhaus GmbH nach DIN EN ISO 9001:2015 (24.04.2019) |
| 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 Zertifizierung der St. Vincenz-Krankenhaus GmbH nach DIN EN ISO 9001:2015 (24.04.2019) |
| RM15 |
Preoperative, complete presentation of necessary findings Zertifizierung der St. Vincenz-Krankenhaus GmbH nach DIN EN ISO 9001:2015 (24.04.2019) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Zertifizierung der St. Vincenz-Krankenhaus GmbH nach DIN EN ISO 9001:2015 (24.04.2019) |
| RM17 |
Standards for recovery and postoperative care Zertifizierung der St. Vincenz-Krankenhaus GmbH nach DIN EN ISO 9001:2015 (24.04.2019) |
| RM18 |
Discharge management Zertifizierung der St. Vincenz-Krankenhaus GmbH nach DIN EN ISO 9001:2015 (24.04.2019) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Patientenarmbänder OP-Checklisten Aktionstag Saubere Hände
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 28.08.2018 |
| 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: bei Bedarf
| 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 |