Dealing with risks in patient care
Quality management
Michael Schmohl
Qualitätamanegementbeauftragter
Ferrenbergstrasse 24
51465 Bergisch Gladbach
Phone:
02202
-122-1581
Mail:
ed.kve@lhomhcs.m
Geschäftsführer, Betriebs- und Pflegedienstleitung, OA Allgemein- und Viszeralchirurgie, OA Innere Medizin, Pflegedienstleitung, Qualitätsmanagementbeauftragte, Mitarbeitervertretung
Conference frequency: quartalsweise
Risk management
Michael Schmohl
Qualitätamanegementbeauftragter
51433 Bergisch Gladbach
Phone:
02202
-122-1581
Fax: 02202-122-1501
Mail:
ed.kve@lhomhcs.m
benannte Risikomangementbeauftragte, Qualitätsmanagement
Conference frequency: halbjährlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikomanagementhandbuch (08.01.2025) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Alarmierung des Notfallteams bei internen Notfällen (20.08.2024) |
| RM05 |
Pain management QMH Schmerztherapie (09.09.2024) |
| RM06 |
Fall prophylaxis Sturzprophylaxe (05.05.2025) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusprophylaxe (05.05.2025) |
| RM08 |
Regulated handling of custodial measures LL Freiheitsentziehende Maßnahmen (14.06.2024) |
| RM09 |
Regulated handling of occurring malfunctions of devices Meldung von schwerwiegenden Vorkommnissen durch die Anwendung und den Betrieb von Medizinprodukten (15.04.2025) |
| 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 Team Time Out, OP-Statut (05.06.2025) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Patientenidentifikationsarmband (20.12.2024) |
| RM17 |
Standards for recovery and postoperative care Postoperative Überwachung (27.07.2024) |
| RM18 |
Discharge management VA Entlassung und Aktenlauf (22.02.2024) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Optimierung der Weitergabe risikobehafteter Medikamente, Ausweitung des Schulungsangebotes,
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 05.02.2024 |
| 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 monatlich |
Conference committee
Conference frequency: halbjährlich
| No. | Explanation |
|---|---|
| EF06 |
CIRS NRW (North Rhine and Westphalia-Lippe Medical Associations, North Rhine-Westphalia Hospital Association, North Rhine and Westphalia-Lippe Associations of Statutory Health Insurance Physicians, German Medical Association) |