Dealing with risks in patient care
Quality management
Diana Bonk
Qualitätsmanagement-Beauftragte
Widumgasse 3
59494 Soest
Phone:
02945
-981-5623
Mail:
gro.lwl@knob.anaid
Leitungskonferenz: Alle Abteilungsleitungen
Conference frequency: monatlich
Risk management
Andreas Rödel
Qualitätsmanagement-Beauftragter
Im Hofholz 6
59556 Lippstadt
Phone:
02945
-981-5622
Fax: 02945-981-1009
Mail:
gro.lwl@ledeor.saerdna
Leitungskonferenz: Alle Abteilungsleitungen
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Konzept Qualitätsmanagement (2024), Konzept Risikomanagement (2021) (27.06.2021) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Verfahrensanweisung Medizinisches Notfallmanagement (07.06.2024) |
| RM05 |
Pain management Verfahrensanweisung Schmerzmanagement (Geronto-/Allg.psychiatrie; 12-2023); Leitfaden Schmerzmittel bei chron. Schmerzen (Depressionsbehandlung; 09-2023) (22.12.2023) |
| RM06 |
Fall prophylaxis Handbuch Leistungskomplexe Pflegedienst (22.12.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Handbuch Leistungskomplexe Pflegedienst (22.12.2023) |
| RM08 |
Regulated handling of custodial measures Dienstanweisung FeM (Fixierung, Isolierung, Intensivierte Betreuung; 11-2023), Verfahrensanweisung Nachbesprechungen von Zwangsmaßn. (03-2023), Verfahrensanweisung Intensive Betreuung (10-2023), Standard Vermeidung FeM (09-2023) (28.11.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Verfahrensanweisung Medizinprodukte - Umgang mit Vorkommnissen (24.10.2022) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM18 |
Discharge management Verfahrensanweisung Entlassmanagement n. SGB V / Entlassvorbereitung (12-2023), Standard Entlassung Suchtmedizin (02-2023) (13.12.2023) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Einführung einer digitalen Medikamentenverordnung.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 05.06.2024 |
| 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 jährlich |
Conference committee
Conference frequency: bei Bedarf
| 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) |