Dealing with risks in patient care
Quality management
Charlotte Kussau
Qualitätsmanagementbeauftragte
Bredenscheider Straße 54
45525 Hattingen
Phone:
0234
-517-1288
Mail:
ed.nekinilk-atsugua@teatilauq
alle Qualitätsmanagementbeauftragten mit einer Person aus der Betriebsleitung
Conference frequency: wöchentlich
Risk management
Charlotte Kussau
Qualitätsmanagementbeauftragte
Bredenscheider Straße 54
45525 Hattingen
Phone:
0234
-517-1288
Fax: 0234-517-1208
Mail:
ed.nekinilk-atsugua@teatilauq
CIRS-Gruppe: Ärzte, Pflege, Pflegemanagement, Qualitätsmanagementbeauftragte, MAV, externe Experten
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available VA Risikomanagement (06.07.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management VA Notfallinformationskette (16.02.2022) |
| RM05 |
Pain management PA Schmerzmanagement im EVK (20.01.2021) |
| RM06 |
Fall prophylaxis PS Sturzprophylaxe (13.02.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) PS Dekubitusprophylaxe / Behandlung (03.11.2021) |
| RM08 |
Regulated handling of custodial measures VA Freiheitseinschränkende Maßnahmen FEM (10.07.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices VA Umgang mit Medizinprodukten (02.03.2017) |
| 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 CL Operative Sicherheit (16.04.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups CL Operative Sicherheit (16.04.2023) |
| RM18 |
Discharge management VA Entlassmanagement (29.01.2018) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Flyer zum Thema Patientensicherheit, Teilnahme am Tag der Patientensicherheit, Software zur Medikamentensicherheit (Wechselwirkungen vermeiden, bessere Lesbarkeit der Anordnung etc...), Patientenlagerungsschulung für OP-Personal, Infomaterial zur sicheren Entsorgung von patienteneigenen Insulinspritzen und Stechhilfen, (Präsenzveranstaltungen coronabedingt nur eingeschränkt möglich)
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 06.07.2023 |
| IF02 |
Internal evaluation of the received reports taken jährlich |
| 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: 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 |