Dealing with risks in patient care
Quality management
Detlef Lawrenz
Stellvertretender Pflegedirektor, Qualitätsmanager und Auditor, klinischer Risikomanager
Schillerstrasse 23
50968 Köln
Phone:
0221
-3793-1212
Mail:
ed.nleok-suinotna@znerwal
Geschäftsführung Krankenhausbetriebsleitung Chefärzte Qualitätsmanagementbeauftragter
Conference frequency: monatlich
Risk management
Detlef Lawrenz
Stellvertretender Pflegedirektor, Qualitätsmanager und Auditor, klinischer Risikomanager
50941 Köln
Phone:
0221
-3793-1212
Fax: 0221-3793-1219
Mail:
ed.nleok-suinotna@znerwal
Geschäftsführung Krankenhausbetriebsleitung Chefärzte Qualitätsmanagementbeauftragter
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitätsmanagementhandbuch (21.04.2023) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management VA interner medizinischer Notfall (06.11.2023) |
| RM05 |
Pain management Schmerzstandard Allgemein- und Visceralchirurgie Schmerzstandard Medizinische Klinik Schmerzstandard Unfall-, Hand- und Orthopädische Chirurgie (21.08.2023) |
| RM06 |
Fall prophylaxis VA Expertenstandard Sturzprophylaxe in der Pflege (15.09.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) VA Expertenstandard Dekubitusprophylaxe in der Pflege (20.06.2021) |
| RM08 |
Regulated handling of custodial measures VA Freiheitsentziehende Maßnahmen (15.09.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices Intranet (15.09.2021) |
| 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 Intranet (15.09.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings Intranet (15.09.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Intranet (15.09.2021) |
| RM17 |
Standards for recovery and postoperative care Intranet (15.09.2021) |
| RM18 |
Discharge management Intranet (15.09.2021) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Patientenarmband Sicherheitscheckliste OP Checkliste Patientenvorbereitung für Untersuchungen Hygienefortbildungen Hygienestandards dokumentiertes Verfahren zur Einweisung in Medizinprodukte standardisierte Einarbeitung neuer Mitarbeiter Notfallmanagement mit jährlichen Mitarbeiterschulungen
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.06.2021 |
| IF02 |
Internal evaluation of the received reports taken quartalsweise |
| 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: quartalsweise
| No. | Explanation |
|---|---|
| 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) |