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Evangelisches Klinikum Bethel gGmbH - Standort Johannesstift

Dealing with risks in patient care

Quality management

Responsible person

Kira Stracke

Leitung Stabsstelle Qualitäts- und Risikomanagement

Schildescher Straße 99
33611 Bielefeld

Phone: 0521 -772-79333
Mail: ed.bkve@ekcarts.arik

Steering committee

Geschäftsführung, Ärztliche Direktion, Pflegedirektion, Kaufmännische Direktion, Theologische Direktion, Klinikentwicklung, Personalmanagement, Erlösmanagement, Unternehmenskommunikation, Controlling

Conference frequency: andere Frequenz

Risk management

Responsible person

Kira Stracke

Leitung Stabsstelle Qualitäts- und Risikomanagement

Phone: 0521 -772-79333
Fax: 0521-772-79340
Mail: ed.bkve@ekcarts.arik

Steering committee

Conference frequency: andere Frequenz

Risk management instruments and measures

Instruments and measures

No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitätsmanagement-Handbuch (22.11.2023)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management z.B. Konzept klinisches Risikomanagement (18.04.2024)
RM05	Pain management z.B. Verfahrensanweisung Schmerzmanagement in der Pflege (18.12.2023)
RM06	Fall prophylaxis Verfahrensanweisung Sturzprävention (25.06.2024)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Verfahrensanweisung Dekubitusprophylaxe in der Pflege (03.05.2024)
RM08	Regulated handling of custodial measures Verfahrensanweisung Freiheitsentziehende Maßnahmen (30.01.2024)
RM09	Regulated handling of occurring malfunctions of devices Verfahrensanweisung Instandsetzung Technik (27.12.2023)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Pathologiebesprechungen Palliativbesprechungen Qualitätszirkel
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 CL OP-Sicherheitscheckliste und Verfahrensanweisung Umgang mit der OP-Sicherheitscheckliste (18.01.2024)
RM15	Preoperative, complete presentation of necessary findings CL OP-Sicherheitscheckliste und Verfahrensanweisung Umgang mit der OP-Sicherheitscheckliste (18.01.2024)
RM16	Procedure to avoid procedural and patient mix-ups CL OP-Sicherheitscheckliste und Verfahrensanweisung Umgang mit der OP-Sicherheitscheckliste (18.01.2024)
RM17	Standards for recovery and postoperative care Qualitätsmanagement-Handbuch (22.11.2023)
RM18	Discharge management z.B. F Ablauf Entlassungsmanagement (22.01.2020)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Definierte u. beschriebene Prozesse (Beschwerdemanagement, Fehler- und Korrekturmanagement, Vorbeugung); System zur Arzneimittel-Therapie-Sicherheit (AMTS); Checklisten (z.B. OP-Sicherheits-Checkliste der WHO); Risikobeurteilung bei allen Patienten (Sturzgefahr, Dekubitus etc.); interne und externe Audits; Mitglied "Aktionsbündnis Patientensicherheit". Einführung Patientenarmbänder (zur Identifikation sowie bei Allergien); Patientenarmbänder, u.v.m

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 27.03.2024
IF02	Internal evaluation of the received reports taken bei Bedarf
IF03	Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken bei Bedarf

No.

Explanation

IF01

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

As of: 27.03.2024

IF02

Internal evaluation of the received reports

taken bei Bedarf

IF03

Training of employees in handling the error reporting system and in implementing the findings from the error reporting system

taken bei Bedarf

Across all institutions

Conference committee

Conference frequency: monatlich

No.	Explanation
	Other
EF01	CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association)
EF06	CIRS NRW (North Rhine and Westphalia-Lippe Medical Associations, North Rhine-Westphalia Hospital Association, North Rhine and Westphalia-Lippe Associations of Statutory Health Insurance Physicians, German Medical Association)

No.

Explanation

Other

EF01

CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association)

EF06

CIRS NRW (North Rhine and Westphalia-Lippe Medical Associations, North Rhine-Westphalia Hospital Association, North Rhine and Westphalia-Lippe Associations of Statutory Health Insurance Physicians, German Medical Association)