Dealing with risks in patient care
Quality management
Dr. med. Susanne Mikle
Qualitätsmanagementbeauftragte
In der Schornau 23-25
44892 Bochum
Phone:
0234
-299-4007
Mail:
ed.muhcob-kk@mq
Geschäftsführung Verwaltungsleitung Pflegedirektion Pflegedienst Betriebsrat Hauswirtschaft Personalabteilung Controlling Innere Medizin Chirurgie Anästhesie Qualitätsmanagement
Conference frequency: monatlich
Risk management
Susanne Mikle
Qualitätsmanagementbeauftragte
In der Schornau 23-25
44892 Bochum
Phone:
0234
-299-4007
Fax: 0234-299-4099
Mail:
ed.muhcob-kk@mq
Geschäftsführung Verwaltungsleitung Pflegedirektion Pflegedienst Betriebsrat Hauswirtschaft Personalabteilung Controlling Innere Medizin Chirurgie Anästhesie Qualitätsmanagement
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Dr. Susanne Mikle (31.10.2019) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Univ.-Prof. Dr. Michael Adamzik (31.10.2019) |
| RM05 |
Pain management Alexander von Busch (16.09.2021) |
| RM06 |
Fall prophylaxis Matthias Birkner Hannah Büscher (10.10.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Matthias Birkner Hannah Büscher (21.12.2022) |
| RM08 |
Regulated handling of custodial measures Matthias Birkner (20.08.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices Michael Jakobs (27.04.2023) |
| 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 OP-Koordinatoren (31.10.2019) |
| RM15 |
Preoperative, complete presentation of necessary findings Matthias Birkner (08.09.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Univ.-Prof. Dr. Kirsten Schmieder (03.02.2022) |
| RM17 |
Standards for recovery and postoperative care Univ.-Prof. Dr. Michael Adamzik (31.10.2019) |
| RM18 |
Discharge management Rainer Banas (31.10.2019) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Frühwarnsystem zur Erhöhung der Patientensicherheit Ziel des Fehlermeldesystems ist die Identifizierung von Risiken in der Patientenversorgung und deren unterstützenden Prozessen, sowie die Auswahl und Einleitung von geeigneten Maßnahmen zur Risikominimierung
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 05.09.2022 |
| IF02 |
Internal evaluation of the received reports taken bei Bedarf |
| IF03 |
Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken monatlich |
Conference committee
Conference frequency: bei Bedarf
| No. | Explanation |
|---|---|
| EF06 |
CIRS NRW (North Rhine and Westphalia-Lippe Medical Chambers, North Rhine Westphalia Hospital Association, North Rhine and Westphalia-Lippe Association of Statutory Health Insurance Doctors, German Medical Association, National Association of Statutory Hea |