Dealing with risks in patient care
Quality management
Eva Kraus
Kommissarische Qualitätsmanagerin
Am Gesundheitspark 11
51375 Leverkusen
Phone:
0214
-13-48125
Mail:
ed.vel-mukinilk@mq
Eva Kraus
Kommissarische Qualitätsmanagerin
Am Gesundheitspark 11
51375 Leverkusen
Phone:
0214
-13-48125
Mail:
ed.vel-mukinilk@mq
QM-Steuerungsgruppe (Betriebsleitung und QM)
Conference frequency: monatlich
Risk management
Eva Kraus
Kommissarische Qualitätsmanagerin
51307 Leverkusen
Phone:
0214
-13-48125
Fax: 0214-13-2865
Mail:
ed.vel-mukinilk@mq
Eva Kraus
Kommissarische Qualitätsmanagerin
51307 Leverkusen
Phone:
0214
-13-48125
Fax: 0214-13-2865
Mail:
ed.vel-mukinilk@mq
QM-Steuerungsgruppe (Betriebsleitung und QM)
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM-Handbuch Nexus Curator (30.09.2021) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Verfahrensanweisung Medizinische Notfälle u. Reanimationen (25.04.2018) |
| RM05 |
Pain management QM-Handbuch Nexus Curator (30.09.2021) |
| RM06 |
Fall prophylaxis QM-Handbuch Nexus Curator (30.09.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) QM-Handbuch Nexus Curator (30.09.2021) |
| RM08 |
Regulated handling of custodial measures QM-Handbuch Nexus Curator (30.09.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices QM-Handbuch Nexus Curator (30.09.2021) |
| 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 Checkliste Sichere OP (23.03.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings Checkliste Sichere Operationen (23.03.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Checkliste Sichere OP (23.03.2021) |
| RM17 |
Standards for recovery and postoperative care Arbeitsanweisung Postoperative Überwachung (23.08.2018) |
| RM18 |
Discharge management Verfahrensanweisung Entlassung (26.09.2018) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Einführung von Risikoaudits, Zertifizierung als schmerzfreies Krankenhaus, Arzneimittelanamnese durch Apotheker, Patienten-Identifikationsarmbänder (Mutter-Kind-Bänder), internes CIRS-Tool
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 11.01.2022 |
| IF02 |
Internal evaluation of the received reports taken monatlich |
| 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: monatlich
| 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 |