Dealing with risks in patient care
Quality management
Katja Badekow
Leitung Qualitätsmanagement
An St. Remigius 26
51379 Leverkusen
Phone:
02171
-409-2009
Mail:
ed.eppurgsulpk@wokedab.ajtak
Herr Thomas Karls (Geschäftsführer), Herr Sascha Wihstutz (Ärztlicher Direktor), Frau Schwab (Pflegedirektorin) und Frau Badekow (Leitung QM)
Conference frequency: monatlich
Risk management
Katja Badekow
Leitung Qualitätsmanagement
Phone:
02171
-409-2009
Fax: 02171-409-2008
Mail:
ed.eppurgsulpk@wokedab.ajtak
Herr Thomas Karls (Geschäftsführer), Herr Sascha Wihstutz (Ärztlicher Direktor), Frau Schwab (Pflegedirektorin) und Frau Badekow (Leitung QM)
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Übergeordnete Risikoerfassungsmatrix (22.08.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Übergeordnete Risikoerfassungsmatrix (22.08.2023) |
| RM05 |
Pain management VA Schmerztherapie allgemein (03.04.2023) |
| RM06 |
Fall prophylaxis Standard Sturzprophylaxe (12.03.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Standard Dekubitusprophylaxe (17.05.2022) |
| RM08 |
Regulated handling of custodial measures Standard zum Umgang mit freiheitsentziehenden Maßnahmen (24.08.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Meldung von Vorkommnissen bei Medizinprodukten /-geräten (15.03.2022) |
| 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 VA OP-Vorbereitung und -Ablauf (17.05.2019) |
| RM15 |
Preoperative, complete presentation of necessary findings VA OP-Vorbereitung und -Ablauf (17.05.2019) |
| RM16 |
Procedure to avoid procedural and patient mix-ups VA OP-Vorbereitung und -Ablauf (17.04.2019) |
| RM17 |
Standards for recovery and postoperative care VA OP-Vorbereitung und -Ablauf (17.12.2019) |
| RM18 |
Discharge management Entlass-Plan in KIS Orbis (21.06.2020) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Es ist ein Fehlermanagement etabliert ebenso wei eine CIRS-Gruppe. Für beides gibt es Meldebögen, die entsprechend bearbeitet und statistisch ausgewertet werden.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 12.08.2020 |
| IF02 |
Internal evaluation of the received reports taken jährlich |
| 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: quartalsweise
| 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 |