Dealing with risks in patient care
Quality management
Dr. rer. nat. Anna Stolze
Leitung Qualitäts- und Risikomanagement
Düesbergweg 124
48153 Münster
Phone:
0251
-976-5800
Mail:
ed.renaixela@ezlots.na
Interdisziplinär
Conference frequency: quartalsweise
Risk management
Anna Stolze
Leitung Qualitäts- und Risikomanagement
Düesbergweg 124
48153 Münster
Phone:
0251
-976-5800
Fax: 0251-976-4440
Mail:
ed.renaixela@ezlots.na
Drei ausgebildete Risikomanager sowie vier weitere Mitarbeitende aus den Bereichen Ärztlicher Dienst, Pflegedienst und Qualitätsmanagement leiten das klinische Risikomanagement im engen Austausch mit der Betriebsleitung.
Conference frequency: wöchentlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Organisationsstatut - QRM (04.09.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Handbuch Notaufnahme (26.04.2024) |
| RM05 |
Pain management Schmerzmanagement (12.04.2024) |
| RM06 |
Fall prophylaxis Leitlinie Sturzprävention und Umgang mit Sturz (24.01.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusmanagement - Pflegerische Handlungsrichtlinie (24.01.2022) |
| RM08 |
Regulated handling of custodial measures VA freiheitsentziehende Maßnahmen (03.08.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Medizintechnik - Organisationshandbuch (26.07.2022) |
| 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 Regelung zur Transfusion von Erythrozyten, Thrombozyten und Plasma (17.10.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Vermeiden von Patientenverwechslung / Handhabung-Patientenarmband (08.02.2024) |
| RM17 |
Standards for recovery and postoperative care Standard zur postoperativen Überwachung (16.09.2022) |
| RM18 |
Discharge management Entlassmanagement (29.11.2023) |
Fault reporting systems
Conference committee
Conference frequency: wöchentlich
Measures
SOP Zentrales Fehler- u. Beschwerdemanagement, Team-Time-Out, präoperative Patientencheckliste nach WHO-Kriterien, SOP Handhabung des Patientenarmbands, Betrieb eines Simulationszentrums im Verbund
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 25.06.2024 |
| 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 jährlich |
Conference committee
Conference frequency: wöchentlich
| 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) |