Dealing with risks in patient care
Quality management
Frau Michaela Schulz
Leitung Qualitätsmanagement
Knappenstrasse 19
59071 Hamm
Phone:
02381
-18-71030
Mail:
ed.mmah-latipsohneiram@zluhcs.aleahcim
Frau Michaela Schulz
Abteilung Qualitätsmanagement
Knappenstrasse 19
59071 Hamm
Phone:
0231
-18-71030
Mail:
ed.mmah-latipsohneiram@zluhcs.aleahcim
Abteilungsleitersitzung auf Trägerebene - Matrixorganisation (2-wöchentliche Sitzung) Klinikleiterkonferenz auf Trägerebene (2-monatliche Sitzung) Betriebsleitungssitzungen (monatliche Sitzung)
Conference frequency: monatlich
Risk management
Michaela Schulz
Abteilung Qualitätsmanagement
Nassauerstraße 13 -19
59065 Hamm
Phone:
0231
-18-71030
Fax: 0231-18-1006
Mail:
ed.mmah-latipsohneiram@zluhcs.aleahcim
Michaela Schulz
Abteilung Qualitätsmanagement
Nassauerstraße 13 -19
59065 Hamm
Phone:
0231
-18-71030
Fax: 0231-18-1006
Mail:
ed.mmah-latipsohneiram@zluhcs.aleahcim
Abteilungsleitersitzung auf Trägerebene - Matrixorganisation (2-wöchentliche Sitzung) Klinikleiterkonferenz auf Trägerebene (2-monatliche Sitzung) Betriebsleitungssitzungen (monatliche Sitzung)
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Intranet (02.05.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Intranet (02.05.2022) |
| RM05 |
Pain management Intranet (02.05.2022) |
| RM06 |
Fall prophylaxis Intranet (02.05.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Intranet (02.05.2022) |
| RM08 |
Regulated handling of custodial measures Intranet (02.05.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Intranet (02.05.2022) |
| 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 (02.05.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings Intranet (02.05.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Intranet (02.05.2022) |
| RM17 |
Standards for recovery and postoperative care Intranet (02.05.2022) |
| RM18 |
Discharge management Intranet (02.05.2022) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Kontinuierliche Optimierung der Patientenversorgung durch Bearbeitung der CIRS-Meldungen sowie Umsetzung von identifizierten Verbesserungsmaßnahmen aus den Auditergebnissen.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 24.08.2021 |
| 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 halbjährlich |
Conference committee
Conference frequency: halbjährlich
| 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 |