Dealing with risks in patient care
Quality management
Sophia Mühlenjost
Mitarbeiterin im Qualitätsmanagement
Buxelstraße 50
33334 Gütersloh
Phone:
05241
-502-2079
Mail:
gro.lwl@tsojnelheum.aihpos
Direktorium, Klinik- und Abteilungsleitungen, QMB
Conference frequency: quartalsweise
Risk management
Frank Hackmann
Abteilungsleitung Dienstleistungen
33326 Gütersloh
Phone:
05241
-502-2198
Fax: 05241-502-2813
Mail:
gro.lwl@nnamkcaH.knarF
Facharzt, PDL, Hygienebeauftragter Arzt, Hygienefachkraft, Fachkraft für Arbeitssicherheit, Medizinproduktekoordinator, Bereichsleitung Bau&Technik, Personalleitung, QM, Personalrat
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Protokoll des Management-Reviews, Risikobericht (19.09.2023) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Prozessbeschreibung D601 Med. Notfall (05.09.2022) |
| RM06 |
Fall prophylaxis Prozessbeschreibung D649 Sturzmanagement (11.09.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Prozessbeschreibung D650 Dekubitusmanagement (11.09.2023) |
| RM08 |
Regulated handling of custodial measures Prozessbeschreibung D608 Freiheitsentziehende Maßnahmen (13.10.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Prozessbeschreibung D837 Medizinprodukte (05.09.2022) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM18 |
Discharge management Prozessbeschreibung D80 Patientenentlassung (14.08.2023) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Organisatorische und bauliche Maßnahmen, Information und Schulung
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 19.09.2023 |
| 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 jährlich |
Conference committee
Conference frequency: quartalsweise
| 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 |