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

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Pathologiebesprechungen
  • Palliativbesprechungen
  • Geriatrische Komplexbehandlung
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