Dealing with risks in patient care

Quality management

Dipl.-Ing. Andrea Pollmeier

Qualitätsmanagementbeauftragte

Dechant-Budde-Weg 3
33428 Harsewinkel

Phone: 05241 -507-4035
Mail: ed.latipsoh-htebasile-tknas@teatilauq

Ärzte, Pflege, IT, Apotheke, QM, Labor, MAV, Physiotherapie, Personalleiter, Hygiene

Conference frequency: bei Bedarf

Risk management

Andrea Pollmeier

Qualitätsmanagementbeauftragte


33245 Gütersloh

Phone: 05241 -507-4035
Fax: 05241-507-4490
Mail: ed.latipsoh-htebasile-tknas@teatilauq

Klinik für Allgemein-, Viszeral-, Thorax- und Minimalinvasive Chirurgie, Klinik für Unfallchirurgie, Pflege, Technik, Qualitätsmanagement, Hygiene, MAV

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

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

Handbuch im Intranet (04.06.2021)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

D6667 Verfahrensanweisung zum innerklinischen Notfallmanagement (07.01.2021)

RM05

Pain management

D1184 Schmerztherapie-Algorithmus (20.10.2021)

RM06

Fall prophylaxis

D8855 Verfahrensanweisung Sturzprophylaxe (27.12.2021)

RM07

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

D12024 Verfahrensanweisung zum Umgang mit dem Expertenstandard "Dekubitusprophylaxe in der Pflege" (27.12.2021)

RM08

Regulated handling of custodial measures

D2138 Standard Freiheitsentziehende Maßnahmen (02.07.2021)

RM09

Regulated handling of occurring malfunctions of devices

D6976 VA zum Umgang mit auftretenden Fehlfunktionen von Geräten (28.12.2021)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Palliativbesprechungen
RM12

Use of standardised information sheets

RM13

Application of standardised surgical check lists

RM18

Discharge management

D10471 Entlassungsplan (30.03.2021)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Interdisziplinäre Risikoaudits

No. Explanation
IF01

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

As of: 06.02.2023

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 monatlich

Conference committee

Conference frequency: monatlich

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