Dealing with risks in patient care
Quality management
Gerlinde Helbig
Qualitätsmanagementbeauftragte, Lob- und Beschwerdemanagement
Virchowstraße 65
32312 Lübbecke
Phone:
05741
-35-2212
Mail:
ed.nekinilksierknelheum@gibleh.ednilreg
Geschäftsführung, Ärztliche Direktoren, Pflegedirektion und Qualitätsmanagementbeauftragte (b. Bedarf)
Conference frequency: monatlich
Risk management
Ina Koch
Qualitätsmanagementbeauftragte / Healthcare Risk Manager
Phone:
05741
-35-2213
Fax: 05741-35-9999
Mail:
ed.nekinilksierknelheum@hcok.ani
Geschäftsführung, Ärztliche Direktoren, Pflegedirektion und Qualitätsmanagementbeauftragte (b. Bedarf)
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available VA-(FP-06)-01 Erstellung und Umgang mit QM-Dokumenten. (24.05.2018) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management SOP-(KP-14)-001 Workflow Notfallalarmierung (28.04.2021) |
| RM05 |
Pain management VA-(KP-36)-001 Schmerzmanagement (28.03.2019) |
| RM06 |
Fall prophylaxis MKK-VA-(KP-18)-01 Sturzprophylaxe (08.03.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) MKK-VA-(KP-17)-01 Dekubitusprophylaxe (03.03.2020) |
| RM08 |
Regulated handling of custodial measures MKK-AA-(KP-18)-01 Freiheitsentziehende Maßnahmen im somatischen Bereich (14.01.2020) |
| 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 VA-(FP-06)-01 Erstellung und Umgang mit QM-Dokumenten. (24.05.2018) |
| RM15 |
Preoperative, complete presentation of necessary findings VA-(FP-06)-01 Erstellung und Umgang mit QM-Dokumenten. (24.05.2018) |
| RM16 |
Procedure to avoid procedural and patient mix-ups VA-KP-07 Patientenversorgung in der Operationseinheit (19.09.2019) |
| RM17 |
Standards for recovery and postoperative care VA-KP-07 Patientenversorgung in der Operationseinheit (07.09.2021) |
| RM18 |
Discharge management VA-(KP-09)-001 Entlassmanagement (27.06.2019) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Morbiditäts- und Mortalitätskonferenzen, Einsatz von Patientenarmbändern, Qualitätszirkel
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 23.09.2013 |
| 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 |