Dealing with risks in patient care
Quality management
Kerstin Breuing
QMB
Aachener Str. 445-449
50933 Köln
Phone:
0221
-94071-458
Mail:
ed.anas@gniuerb.nitsrek
Alle Führungskräfte des Hauses
Conference frequency: andere Frequenz
Risk management
Kerstin Breuing
QMB
Aachener Str. 445-449
50933 Köln
Phone:
0221
-94071-458
Mail:
ed.anas@gniuerb.nitsrek
Alle Führungskräfte des Hauses
Conference frequency: andere Frequenz
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available VA CIRS (3.11.2020), VA ERiKA Fallanalyse und ERiKA-light Fallanalyse (08.08.2023), VA Interne Audits (8.7.2021), VA Interprofessionelles Peer Review (14.03.2023), VA MoMo-Konferenz (18.11.2020) (12.09.2023) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management VA Reanimation (21.10.2021) |
| RM05 |
Pain management VA Perioperative Schmerztherapie (11.01.2021) |
| RM06 |
Fall prophylaxis MD Expertenstandard Sturz (23.05.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) MD Expertenstandard Dekubitus (27.04.2022) |
| RM08 |
Regulated handling of custodial measures VA FEM Freiheitsentziehende Maßnahmen (01.05.2018) |
| RM09 |
Regulated handling of occurring malfunctions of devices QMD Samba Handbuch (es sind ausreichend Ersatzgeräte im Haus vorhanden, so dass die Patientensicherheit jederzeit gewährleistet ist) (17.08.2021) |
| 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 VA Team Time Out (04.02.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings VA Team Time Out -TTO- (04.02.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups VA Team Time Out -TTO- (04.02.2022) |
| RM17 |
Standards for recovery and postoperative care VA Post OP Versorgung AWR (27.10.2021) und VA Post OP Versorgung Intensivstation (22.11.2021) (22.11.2021) |
| RM18 |
Discharge management VA Entlassmanagemnt akut und Entlassmanagement Patienteninformation und Einwilligung (02.03.2020), AA Entlassmanagement Sozialdienst (09.08.2022) (09.08.2022) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Patientenidentifikationsarmband, 4-Augen-Prinzip Medikamentenstellung und Auswertung, "Allergien und Unverträglichkeiten" im OP-Plan, Team Time Out
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 23.10.2020 |
| 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 bei Bedarf |
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 |