Dealing with risks in patient care
Quality management
Sven Gralewski
Qualitäts- und Risikomanagementbeauftragter
Rottstraße 11
45711 Datteln
Phone:
02363
-108-2005
Mail:
ed.hbmg-kcv@ikswelarg.s
QMB, Geschäftsführung, ärztlicher Dienst, Pflegedienst, EDV-Abteilung, Öffentlichkeitsarbeit, und weitere nach Bedarf
Conference frequency: wöchentlich
Risk management
Sven Gralewski
Qualitäts- und Risikomanagementbeauftragter
Phone:
02363
-108-2005
Mail:
ed.hbmg-kcv@ikswelarg.s
Krankenhausbetriebsleitung, QMB
Conference frequency: jährlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikomanagement der Vestischen Caritas-Kliniken GmbH Geschäftsbereich Erwachsene (10.02.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management VA „Notfallmanagement“, zusätzlich zertifizierte "Chest Pain Unit" (05.12.2022) |
| RM05 |
Pain management Name: Verschiedene Dokumente zum Schmerzmanagement (inkl. Expertenstandard) (25.07.2023) |
| RM06 |
Fall prophylaxis Pflegestandard Sturzprophylaxe (14.12.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Pflegestandard Dekubitusprophylaxe (14.12.2022) |
| RM08 |
Regulated handling of custodial measures Vermeidung von und Umgang mit freiheitsbeschränkenden und freiheitsentziehenden Maßnahmen (30.11.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices Organisationshandbuch Medizintechnik (01.03.2021) |
| 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 Formular „Sicherheitscheckliste OP (WHO)“ (28.11.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings Formular "Checkliste zur präoperativen Patientenvorbereitung" (19.06.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups VA „Positive Patientenidentifikation mit Patientenarmband nach MPG" (16.03.2021) |
| RM17 |
Standards for recovery and postoperative care VA „Aufwachraum“ (13.10.2021) |
| RM18 |
Discharge management Verschiedene VAs, z.B. Expertenstandard Entlassmanagement (11.03.2021) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Überprüfung/ Austausch von Med.-Produkten, Prozessoptimierung der Medikamentenanordnung, Prozessanpassung in der Aufnahme zur Patientenidentifikation, Verlegung der Serverwartung in die Abendstunden
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 18.01.2023 |
| 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 halbjährlich |
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 |