Dealing with risks in patient care
Quality management
Sabine Reppin
Qualitätsmanagementbeauftragte
Röntgenstr. 10
45661 Recklinghausen
Phone:
02361
-601-119
Mail:
ed.enilnoke@nipper.enibas
Projektsteuerungsgruppe: Geschäftsführung, Mitarbeitervertretung, Medizinische Fachbereiche, Pflegedienst, Qualitätsmanagement, Risikomanagement, Seelsorge
Conference frequency: halbjährlich
Risk management
Boris Mönter
Oberarzt Geriatrie/Neurologie
Röntgenstr. 10
45661 Recklinghausen
Phone:
02361
-601-6441
Fax: 02361-601-299
Mail:
ed.enilnoke@retneom.sirob
Controlling, Geschäftsführung, Medizinische Fachbereiche, Pflegedienst, Qualitätsmanagement, Stabsstelle Klinisches Risikomanagement. Bei Bedarf werden weitere Abteilungen eingeladen.
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Rahmenkonzept Risikomanagement (06.12.2021) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Der Notfall: Erkennen Analysieren Handeln (13.05.2022) |
| RM05 |
Pain management Behandlung von Schmerzpatienten (03.03.2022) |
| RM06 |
Fall prophylaxis Sturzprophylaxe (22.04.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusprophylaxe (24.03.2022) |
| RM08 |
Regulated handling of custodial measures Verfahrensanweisung Fixierung (18.09.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Organisationshandbuch Medizintechnik (24.10.2023) |
| 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 Sicherheits-Checkliste ZOP Team-Time-Out (24.02.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Aufnahme eines Patienten (21.12.2021) |
| RM17 |
Standards for recovery and postoperative care Aufnahme und Überwachung eines ambulanten Patienten im Zentrum für ambulantes Operieren (11.08.2021) |
| RM18 |
Discharge management Konzept Entlassmanagement (21.03.2018) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Patientenarmbänder
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 06.07.2023 |
| 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: quartalsweise
| 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 |