Dealing with risks in patient care

Quality management

Katja Müller

zertifizierte Risiko- und Nachhaltigkeitsmanagerin

Kiskerstr. 15
33615 Bielefeld

Phone: 0521 -96432-7020
Mail: ed.gotrahrdkinilk@relleum.ajtak

Qualitätsmanagement, Geschäftsführung, ärztliche Leitung, Abteilungsleitungen, Risikomanagement, Führungskräfte, Nachhaltigkeitsmanagement und Mitarbeiter nach Bedarf

Conference frequency: wöchentlich

Risk management

Katja Müller

zertifizierte Risiko- und Nachhaltigkeitsmanagerin

Phone: 0521 -96432-7020
Fax: 0521-96432-29
Mail: ed.gotrahrdkinilk@relleum.ajtak

Leitung Risikomanagement, Geschäftsführung, arztliche Leitung, Medizincontrolling, Bereichsleitung einzelner Bereiche nach Bedarf

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

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

Qualitätsmanagementhandbuch (01.09.2023)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Qualitätsmanagementhandbuch (01.09.2023)

RM05

Pain management

Qualitätsmanagementhandbuch (01.09.2023)

RM06

Fall prophylaxis

Qualitätsmanagementhandbuch (01.09.2023)

RM07

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

Qualitätsmanagementhandbuch (01.09.2023)

RM09

Regulated handling of occurring malfunctions of devices

Qualitätsmanagementhandbuch (01.09.2023)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Qualitätszirkel
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

Qualitätsmanagementhandbuch (01.09.2023)

RM15

Preoperative, complete presentation of necessary findings

Qualitätsmanagementhandbuch (01.09.2023)

RM16

Procedure to avoid procedural and patient mix-ups

Qualitätsmanagementhandbuch (01.09.2023)

RM17

Standards for recovery and postoperative care

Qualitätsmanagementhandbuch (01.09.2023)

RM18

Discharge management

Qualitätsmanagementhandbuch (01.09.2023)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Standartisierte Patientenkennzeichnung mittels Armbändern Visuelle Allergie- und Komorbiditäskennzeichnung der Patientenakten und Betten CIRS Management

No. Explanation
IF01

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

As of: 02.11.2020

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 bei Bedarf

Conference committee

Conference frequency: monatlich

No. Explanation
EF14

CIRS Health Care