Dealing with risks in patient care
Quality management
Claudia Meßthaler
Klinikgeschäftsführung
Albertus-Magnus Straße 33
47259 Duisburg
Phone:
0203
-755-1605
Mail:
ed.tiehdnuseg-soileh@relahtssem.aidualc
Conference frequency:
Risk management
Claudia Meßthaler
Klinikgeschäftsführung
Phone:
0203
-755-1605
Fax: 0203-755-1610
Mail:
ed.tiehdnuseg-soileh@relahtssem.aidualc
Das CIRS Team setzt sich pro Haus wie folgt zusammen: QM-Beauftragter Mitarbeiter, Pflegedirektion, Ärztliche Direktion, Geschäftsführung
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM05 |
Pain management Handlungsempfehlung Schmerzmanagement in der Pflege bei akuten und chronischen Schmerzen (15.07.2022) |
| RM06 |
Fall prophylaxis Beschluss der FG Pflege Sturzprophylaxe (01.02.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Beschluss der FG Pflege Dekubitusprophylaxe (01.11.2021) |
| RM08 |
Regulated handling of custodial measures |
| RM09 |
Regulated handling of occurring malfunctions of devices Verfahrensstandard Umgang mit Produktproblemen (ZD Einkauf) (06.12.2022) |
| 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 Konzernregelung OP-Sicherheit (27.01.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings Konzernregelung OP-Sicherheit (27.01.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Konzernregelung OP-Sicherheit (27.01.2022) |
| RM17 |
Standards for recovery and postoperative care |
| RM18 |
Discharge management |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
- Einführung von Patientenarmbändern - Einsatz und Optimierung von Checklisten im OP - Fortbildungsmaßnahmen - Optimierung von Verfahrens- und Prozessbeschreibungen - Verbesserte Regelungen von Verantwortlichkeiten
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 03.07.2023 |
| 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 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 |