Dealing with risks in patient care
Quality management
Dr. Anna Stolze
Leiterin Qualitäts- und Risikomanagement
Loerstraße 23
48143 Münster
Phone:
0251
-976-5800
Mail:
ed.renaixela@ezlots.na
Jens Lammers
Leiter Qualitäts- und Risikomanagement
Loerstraße 23
48143 Münster
Phone:
0251
-976-5909
Mail:
ed.renaixela@sremmal.snej
Jens Lammers
Leiter Qualitäts- und Risikomanagement
Loerstraße 23
48143 Münster
Phone:
0251
-976-5909
Mail:
ed.renaixela@sremmal.snej
Interdisziplinär
Conference frequency: halbjährlich
Risk management
Jens Lammers
Leiter Qualitäts- und Risikomanagement
Loerstraße 23
48143 Münster
Phone:
0251
-976-5909
Mail:
ed.renaixela@sremmal.snej
Jens Lammers
Leiter Qualitäts- und Risikomanagement
Loerstraße 23
48143 Münster
Phone:
0251
-976-5909
Mail:
ed.renaixela@sremmal.snej
vier Risikomanager aus den Bereichen Ärztlicher Dienst, Pflegedienst, Qualitätsmanagement leisten das operative Geschäft und tauschen sich regelmäßig aus.
Conference frequency: wöchentlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Geschäftsordnung Qualitäts- und Risikomanagement (22.06.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Klinisches Notfallmanagement (04.10.2021) |
| RM05 |
Pain management Schmerzmanagement Handbuch Raphaelsklinik (23.09.2020) |
| RM06 |
Fall prophylaxis Leitlinie Sturzprävention und Umgang mit Sturz (24.01.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusprophylaxe - Pflegerische Handlungsrichtlinie (24.01.2022) |
| RM08 |
Regulated handling of custodial measures VA freiheitsentziehende Maßnahmen (03.08.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Medizintechnik - Organisationshandbuch (26.07.2022) |
| 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 Geschäftsordnung OP (23.03.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings Geschäftsordnung OP (23.03.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Handhabung-Patientenarmband (28.06.2023) |
| RM17 |
Standards for recovery and postoperative care Postoperative Routineüberwachung auf der Normalstation (04.10.2022) |
| RM18 |
Discharge management Entlassmanagement (17.10.2022) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
SOP Zentrales Fehler- u. Beschwerdemanagement, Strukturierte OP-Checkliste, Team-Time-Out, präoperative Patientencheckliste nach WHO-Kriterien, Patientenidentifikation durch Armbänder, Dolmetscherdienst, Ausweitung des Reanimationstrainings ( MegaCode), Deeskalationstraining
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 05.12.2022 |
| 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: 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 |