Dealing with risks in patient care
Quality management
Inna Rifert
Leitung Regionalbereich Qualitätsmanagement
Husener Str. 46
33098 Paderborn
Phone:
05251
-702-2250
Mail:
ed.eppurgtbb@trefir.i
Medizin, Pflege, Verwaltung
Conference frequency: quartalsweise
Risk management
Inna Rifert
Leitung Regionalbereich Qualitätsmanagement
Husener Straße 46
33098 Paderborn
Phone:
05251
-702-2250
Mail:
ed.eppurgtbb@trefir.i
Medizin, Pflege, Verwaltung
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Digitales QM-Handbuch (31.12.2024) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Notfall im Krankenhaus (04.06.2025) |
| RM05 |
Pain management VA zur Anordnung, Durchführung, Fortführung u. Überwachung schmerztherapeutischer Maßnahmen (11.04.2024) |
| RM06 |
Fall prophylaxis Expertenstandard Sturzprophylaxe Pflege (21.08.2025) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitusprophylaxe (04.06.2025) |
| RM08 |
Regulated handling of custodial measures Freiheitsentziehende Maßnahmen /- auf der Intensivstation (27.10.2025) |
| RM09 |
Regulated handling of occurring malfunctions of devices Digitales Meldesystem der Medizintechnik (31.12.2024) |
| 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 Prozess Team Time Out (07.10.2025) |
| RM15 |
Preoperative, complete presentation of necessary findings OP Checkliste Vorbereitung (07.10.2025) |
| RM16 |
Procedure to avoid procedural and patient mix-ups OP Statut (07.10.2025) |
| RM17 |
Standards for recovery and postoperative care Stufenschema für Aufwachraum und postoperative Schmertherapie, Postoperatives Delirmanagement, Vermeidung von Hypothermie Postoperative Standard für Pflege (11.04.2024) |
| RM18 |
Discharge management Prozessbeschreibung (31.12.2024) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Alle Vorkommnisse werden exakt auf Ursache und Auswirkung analysiert. Es folgt die Festlegung einer Maßnahme, die präventiv an der Ursache ansetzt. Die Umsetzung der Maßnahme wird vom QM begleitet.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.07.2025 |
| IF02 |
Internal evaluation of the received reports taken halbjährlich |
| 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: jährlich
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |
| 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) |