Dealing with risks in patient care
Quality management
Dipl. Pflegewirtin Anne Panzer
Teamleitung des Allg. QM an den Standorten Borken, Bocholt und Rhede
Barloer Weg 125
46397 Bocholt
Phone:
02871
-20-2544
Mail:
ed.lmwk@reznap.enna
Mitglieder der KBL, MAV, QM, Vertreter aus den Abteilungen/ Funktionsbereichen
Conference frequency: monatlich
Risk management
Anne Panzer
Teamleitung des Allg. QM an den Standorten Borken, Bocholt und Rhede
Phone:
02871
-20-2544
Fax: 02871-20-2363
Mail:
ed.lmwk@reznap.enna
Mitglieder der KBL, Leitung Zentralapotheke, Teamleitung allg. QM/RM, MA allg. QM/ klin. RM SAH/SVH
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Teil der QM/RM Dokumentation (31.12.2021) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Teil der QM/RM Dokumentation (31.12.2021) |
| RM05 |
Pain management Teil der QM/RM Dokumentation (31.12.2021) |
| RM06 |
Fall prophylaxis Teil der QM/RM Dokumentation (31.12.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Teil der QM/RM Dokumentation (31.12.2021) |
| RM08 |
Regulated handling of custodial measures Teil der QM/RM Dokumentation (31.12.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices Teil der QM/RM Dokumentation (31.12.2021) |
| 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 Teil der QM/RM Dokumentation (31.12.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings Teil der QM/RM Dokumentation (31.12.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Teil der QM/RM Dokumentation (31.12.2021) |
| RM17 |
Standards for recovery and postoperative care Teil der QM/RM Dokumentation (31.12.2021) |
| RM18 |
Discharge management Teil der QM/RM Dokumentation (31.12.2021) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Anwendung Patientenidentifikationsarmband- Aufbau Info Seite Intranet; Schulungsmaterial für Mitarbeiter - Einsatz OP- Sicherheitscheckliste - Maßnahmen zur Arzneimitteltherapiesicherheit - Verbesserung der Sturzprävention - Patientendokumentationschecklisten - Beschwerdemanagement- Risiko- Audits (übergreifend)- Maßnahmenableitungen aus Befragungen (Mitarbeiter, Einweiser, Patienten)- Auswertung externer QS- Bekanntmachung von Quick- Alerts
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 31.12.2021 |
| 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 |
|---|---|
|
Other |
|
| 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 |