Dealing with risks in patient care

Quality management

Herr Dirk Tedeschi

Leitung Qualitätsmanagement

Renntormauer 1-3
32052 Herford

Phone: 0521 -589-9010
Mail: ed.dlefeleib-ohk@ihcsedet.krid

Geschäftsführung, Qualitätsmanagement, Personalabteilung, Kaufmännische Leitung Zu spezifischen Themen werden weitere Personen gezielt eingeladen.

Conference frequency: jährlich

Risk management

Dirk Tedeschi

Leitung Qualitätsmanagement

Renntormauer 1-3
32052 Herford

Phone: 0521 -589-9010
Fax: 0521-589-9004
Mail: ed.dlefeleib-ohk@ihcsedet.krid

Geschäftsführung, Qualitätsmanagement, Ärztliche Direktoren, Pflegedienstleitung, Kaufmännische Leitung

Conference frequency: jährlich

Risk management instruments and measures

No. Explanation
RM01

Comprehensive quality and/or risk management documentation (QM/RM documentation) is available

KHONet, Intranet (21.05.2025)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

KHONet, Intranet (21.05.2025)

RM05

Pain management

KHONet, Intranet (21.05.2025)

RM06

Fall prophylaxis

KHONet, Intranet (21.05.2025)

RM07

Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”)

KHONet, Intranet (21.05.2025)

RM08

Regulated handling of custodial measures

KHONet, Intranet (21.05.2025)

RM09

Regulated handling of occurring malfunctions of devices

KHONet, Intranet (21.05.2025)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Qualitätszirkel
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

KHONet, Intranet (21.05.2025)

RM15

Preoperative, complete presentation of necessary findings

KHONet, Intranet (21.05.2025)

RM16

Procedure to avoid procedural and patient mix-ups

KHONet, Intranet (21.05.2025)

RM17

Standards for recovery and postoperative care

KHONet, Intranet (21.05.2025)

RM18

Discharge management

KHONet, Intranet (21.05.2025)

Fault reporting systems

Conference committee

Conference frequency: bei Bedarf

Measures

Digitalisierung

No. Explanation
IF01

Documentation and procedural instructions for handling the error reporting system are available

As of: 21.05.2025

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: bei Bedarf

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)