Dealing with risks in patient care

Quality management

Axel Klein

Abteilungsleiter Medizincontrolling und Qualitätsmanagement

Wilhelm-Breckow-Allee 20
51643 Gummersbach

Phone: 02291 -82-2525
Mail: ed.grebrebo-mukinilk@nielk.lexa

Conference frequency:

Risk management

Magnus Kriesten

Geschäftsführer


51643 Gummersbach

Phone: 02261 -17-0
Fax: 02261-17-2002
Mail: ed.grebrebo-mukinilk@ofni

Conference frequency:

Risk management instruments and measures

No. Explanation
RM01

Comprehensive quality and/or risk management documentation (QM/RM documentation) is available

Verfahrensanweisungen (06.04.2023)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Verfahrensanweisungen (06.04.2023)

RM05

Pain management

Verfahrensanweisungen (06.04.2023)

RM06

Fall prophylaxis

Verfahrensanweisungen (06.04.2023)

RM07

Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”)

Verfahrensanweisungen (06.04.2023)

RM08

Regulated handling of custodial measures

Verfahrensanweisungen (06.04.2023)

RM09

Regulated handling of occurring malfunctions of devices

Verfahrensanweisungen (06.04.2023)

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

RM16

Procedure to avoid procedural and patient mix-ups

Verfahrensanweisungen (06.04.2023)

RM17

Standards for recovery and postoperative care

Verfahrensanweisungen (06.04.2023)

RM18

Discharge management

Verfahrensanweisungen (06.04.2023)

Fault reporting systems

Conference committee

Conference frequency: andere Frequenz

Measures

CIRS

No. Explanation
IF01

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

As of: 03.04.2023

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: andere Frequenz

No. Explanation
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