Dealing with risks in patient care
Quality management
Mirko Hersemann
Qualitätsmanagementbeauftragter
Hans-Nolte-Str. 1
32429 Minden
Phone:
0571
-790-2063
Mail:
ed.nekinilksierknelheum@nnamesreh.okrim
Strategiekonferenz
Conference frequency: wöchentlich
Risk management
Mirko Hersemann
Qualitätsmanagementbeauftragter
Phone:
0571
-790-2063
Mail:
ed.nekinilksierknelheum@nnamesreh.okrim
Strategiekonferenz
Conference frequency: wöchentlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018) |
| RM05 |
Pain management MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018) |
| RM06 |
Fall prophylaxis MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018) |
| RM08 |
Regulated handling of custodial measures MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018) |
| RM09 |
Regulated handling of occurring malfunctions of devices MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018) |
| 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 MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018) |
| RM15 |
Preoperative, complete presentation of necessary findings MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018) |
| RM16 |
Procedure to avoid procedural and patient mix-ups MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018) |
| RM17 |
Standards for recovery and postoperative care MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018) |
| RM18 |
Discharge management MKK-VA-(FP-02)-101 Organisation des Instituts für Qualitäts- und Risikomanagement (09.08.2018) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Einsatz von Patientenarmbändern, Qualitätszirkel, MRSA/MRE Screening, Begehungen (Hygiene, Arbeitsschutz, Brandschutz), Morbiditäts- und Mortalitätskonferenzen, Sturzprophylaxe, Dekubitusprophylaxe, Audits, Risikoanalysen, Befragungen (Einweiser, Patienten), Beschwerdemanagement
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.03.2017 |
| IF02 |
Internal evaluation of the received reports taken bei Bedarf |
| 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: bei Bedarf
| No. | Explanation |
|---|---|
| EF01 |
CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, 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 |