Dealing with risks in patient care
Quality management
Sarah Lückenbach
Abteilungsleitung Organisation und Qualitätsmanagement
St. Elisabethstraße 2-6
53894 Mechernich
Phone:
02443
-17-1044
Mail:
ed.mhkk@hcabnekceul.haras
Geschäftsführung, Ärztliche Direktion, Pflegedirektion, Abteilungsleitung Organisation und Qualitätsmanagement (QMB), Personalleitung, Betriebsratsvorsitzende
Conference frequency: halbjährlich
Risk management
Sarah Lückenbach
Abteilungsleitung Organisation und Qualitätsmanagement
Phone:
02443
-17-1044
Fax: 02443-17-1005
Mail:
ed.mhkk@hcabnekceul.haras
Geschäftsführung, Ärztliche Direktion, Pflegedirektion, Abteilungsleitung Organisation und Qualitätsmanagement (QMB), Personalleitung, Betriebsratsvorsitzende
Conference frequency: halbjährlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM-Handbuch / Nexus Curator (16.04.2024) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Nexus Curator Innerklinischer Notfall - Polytrauma - Schockraummanagement - Notsectio (30.07.2024) |
| RM05 |
Pain management Verfahrensanweisung Schmerzmanagement (04.05.2023) |
| RM06 |
Fall prophylaxis Verfahrensanweisung Sturzprophylayxe Nexus Curator (03.05.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Verfahrensanweisung Dekubitusmanagement / Nexus Curator (03.05.2023) |
| RM08 |
Regulated handling of custodial measures Verfahrensanweisungen zum Umgang mit Freiheitsentziehenden Maßnahmen / Nexus Curator (15.05.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Dienstanweisung / Nexus Curator (11.10.2023) |
| 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 QM-Handbuch / Nexus Curator (16.04.2024) |
| RM15 |
Preoperative, complete presentation of necessary findings QM-Handbuch / Nexus Curator (16.04.2024) |
| RM16 |
Procedure to avoid procedural and patient mix-ups QM-Handbuch / Nexus Curator (16.04.2024) |
| RM17 |
Standards for recovery and postoperative care QM-Handbuch / Nexus Curator (16.04.2024) |
| RM18 |
Discharge management QM-Handbuch / Nexus Curator (16.04.2024) |
Fault reporting systems
Conference committee
Conference frequency: andere Frequenz
Measures
Eine Fehlermeldung im CIRS-Meldewesen ist jederzeit möglich. Die Meldung wird anonymisiert in einer Arbeitsgruppe bearbeitet und ggfs. Maßnahmen abgeleitet. Eine Rückmeldungen über Maßnahmen aus dem CIRS-Meldewesen erfolgt, wenn die Kontaktdaten angegeben wurden. Abgelitete Maßnahmen werden im QM-/RM Dokumentationssystem aufgeführt.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.08.2024 |
| 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: andere Frequenz
| No. | Explanation |
|---|---|
| EF01 |
CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association) |
| 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) |