Dealing with risks in patient care

Quality management

Dipl. Pflegewirtin (FH) Simone Ehlers

Qualitäts- und Risikomanagement

Bonner Talweg 4-6
53113 Bonn

Phone: 0228 -506-2122
Mail: ed.nnob-kg@srelhe.s

Sitzung der Qualitäts- und Risikomanagementbeauftragten, 49 Mitglieder aus allen Abteilungen und Funktionsbereichen

Conference frequency: quartalsweise

Risk management

Simone Ehlers

Qualitäts- und Risikomanagement

Bonner Talweg 4-6
53113 Bonn

Phone: 0228 -506-2122
Fax: 0228-506-32122
Mail: ed.nnob-kg@srelhe.s

Risikomanagerin und Risikobeauftragte aus den Abteilungen/Funktionsbereichen

Conference frequency: halbjährlich

Risk management instruments and measures

No. Explanation
RM01

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

Handbuch Risikomanagement BBT, Jährliche Managementbewertung nach DIN EN ISO (27.09.2021)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Notfallmanagement (15.12.2020)

RM05

Pain management

Leitfaden Akutschmerztherapie (13.06.2023)

RM06

Fall prophylaxis

Sturzprophylaxe (03.07.2023)

RM07

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

Dekubitusprophylaxe (03.07.2023)

RM08

Regulated handling of custodial measures

Verfahrensanweisung Freiheitsbeschränkende Maßnahmen (02.07.2020)

RM09

Regulated handling of occurring malfunctions of devices

VA zur Umsetzung der MPBetreibV (16.01.2023)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Geriatrische Fallbesprechungen
  • Alterstraumatologische Fallbesprechungen
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

Anwendung der WHO-OP-Checkliste (18.05.2020)

RM15

Preoperative, complete presentation of necessary findings

OP-Checkliste (18.05.2020)

RM16

Procedure to avoid procedural and patient mix-ups

VA Patientenidentifikation und OP-Checkliste (07.08.2019)

RM17

Standards for recovery and postoperative care

Übergabe Aufwachraum an Normalstation und an Intensivstation; OP-Saalkarte (09.04.2020)

RM18

Discharge management

Entlassungsmanagement (11.08.2022)

Fault reporting systems

Conference committee

Conference frequency: andere Frequenz

Measures

Anpassung / Neuerstellung von Verfahrensanweisungen, Schulung von Mitarbeitern, Sensibilisierung durch Veröffentlichung von CIRS-Fällen im Intranet

No. Explanation
IF01

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

As of: 24.01.2022

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: jährlich

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