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
Qualitätsmanagement, Geschäftsführung, ärztliche Leitung, Abteilungsleitungen, Risikomanagement, Führungskräfte, Nachhaltigkeitsmanagement und Mitarbeiter nach Bedarf
Conference frequency: wöchentlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitätsmanagementdokumentation (18.09.2025) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Qualitätsmanagementdokumentation (18.09.2025) |
| RM05 |
Pain management Qualitätsmanagementdokumentation (18.09.2025) |
| RM06 |
Fall prophylaxis Qualitätsmanagementdokumentation (18.09.2025) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Qualitätsmanagementdokumentation (18.09.2025) |
| RM09 |
Regulated handling of occurring malfunctions of devices Qualitätsmanagementdokumentation (18.09.2025) |
| 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 Qualitätsmanagementdokumentation (18.09.2025) |
| RM15 |
Preoperative, complete presentation of necessary findings Qualitätsmanagementdokumentation (18.09.2025) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Qualitätsmanagementdokumentation (18.09.2025) |
| RM17 |
Standards for recovery and postoperative care Qualitätsmanagementdokumentation (18.09.2025) |
| RM18 |
Discharge management Qualitätsmanagementdokumentation (18.09.2025) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Standardisierte Patientenkennzeichnung mittels Armbändern Visuelle Allergie- und Komorbiditäskennzeichnung der Patientenakten und Betten CIRS Management, Fehleranalysen nach dem London-Protokoll
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 16.07.2025 |
| 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 |