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 (31.07.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Notfall im Krankenhaus (31.07.2023) |
| RM05 |
Pain management Stufenschema des Akutschmerzdienstes (31.07.2023) |
| RM06 |
Fall prophylaxis Expertenstandard Sturzprophylaxe (31.07.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitusprophylaxe (31.07.2023) |
| RM08 |
Regulated handling of custodial measures Prozessbeschreibung (31.12.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Digitales Meldesystem (31.12.2022) |
| 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 Time Time Out (31.12.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings Prozess Time Time Out (31.12.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Prozessbeschreibung (31.12.2022) |
| RM17 |
Standards for recovery and postoperative care Prozessbeschreibung (31.12.2022) |
| RM18 |
Discharge management Prozessbeschreibung (31.12.2022) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Risikoaudits
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 31.10.2024 |
| 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 bei Bedarf |
Conference committee
Conference frequency: bei Bedarf
| 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) |