Dealing with risks in patient care
Quality management
Alexandra West
Qualitätsmanagementbeauftragte
Asberger Str. 4
47441 Moers
Phone:
02841
-107-13180
Mail:
ed.sreom-fesoj-ts@tsew.ardnaxela
Betriebsleitung und direkte Anbindung der Leitung des Zentralen QM über monatliches JourFixe mit der Geschäftsführung.
Conference frequency: monatlich
Risk management
Alexandra West
Qualitätsmanagementbeauftragte
Phone:
02841
-107-13180
Fax: 02841-107-14301
Mail:
ed.sreom-fesoj-ts@tsew.ardnaxela
Betriebsleitung und direkte Anbindung der Leitung des Zentralen QM über monatliches JourFixe mit der Geschäftsführung.
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Organisationshandbuch (08.09.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Organisationshandbuch (08.09.2022) |
| RM05 |
Pain management Organisationshandbuch (08.09.2022) |
| RM06 |
Fall prophylaxis Organisationshandbuch (08.09.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Organisationshandbuch (08.09.2022) |
| RM08 |
Regulated handling of custodial measures Organisationshandbuch (08.09.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Organisationshandbuch (08.09.2022) |
| 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 Organisationshandbuch (08.09.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings Organisationshandbuch (08.09.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Organisationshandbuch (08.09.2022) |
| RM17 |
Standards for recovery and postoperative care Organisationshandbuch (08.09.2022) |
| RM18 |
Discharge management Organisationshandbuch (08.09.2022) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Identifikationsarmband OP Checklisten, Team Time Out interne Audits Begehungen (Arbeitssicherheit) Hygienebegehungen Notfallmanagement / Intoxikation Reanimationsübungen Medikationskontrollen ABS Team Überarbeitung "Funkmanagement" Schulungen zum Patientenrechtegesetz Peer Reviews im Pflegedienst Fall- und Mortalitätsbesprechungen im ärztlichen Dienst
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 10.06.2020 |
| IF02 |
Internal evaluation of the received reports taken jährlich |
| 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: monatlich
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors) |
| 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 |