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
|
| 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 |