Dealing with risks in patient care

Quality management

Dr. Andreas Hellwig

Geschäftsbereichsleiter Medizinmanagement

Parkstraße 15
44866 Bochum

Phone: 0234 -509-8899
Mail: ed.oblkk@mq

Alle klinischen und betrieblichen Fachabteilungen.

Conference frequency: halbjährlich

Risk management

Andreas Hellwig

Geschäftsbereichsleiter Medizinmanagement, Risikomanagementhauptverantwortlicher KKB

Parkstraße 15
44866 Bochum

Phone: 0234 -509-8899
Mail: ed.oblkk@mq

Geschäftsbereichsleiter Risikomanagement / Risikomanagementhauptverantwortlicher KKB / Qualitätsmanager, betrieblicher und klinischer Risikomanager inkl. Stellvertreter

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

Comprehensive quality and/or risk management documentation (QM/RM documentation) is available

Managementhandbuch (31.05.2019)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Managementhandbuch (17.07.2018)

RM05

Pain management

Managementhandbuch (31.12.2015)

RM06

Fall prophylaxis

Managementhandbuch (14.04.2020)

RM07

Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”)

Managementhandbuch (30.12.2017)

RM08

Regulated handling of custodial measures

Managementhandbuch (21.03.2016)

RM09

Regulated handling of occurring malfunctions of devices

Managementhandbuch (19.12.2019)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Pathologiebesprechungen
  • Palliativbesprechungen
  • Radiologiebesprechungen
  • GERD-Teamsitzungen
RM12

Use of standardised information sheets

RM16

Procedure to avoid procedural and patient mix-ups

Managementhandbuch (21.12.2020)

RM18

Discharge management

Managementhandbuch (25.02.2020)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

z. B. Wechsel eines Inhalationssystems, Anschaffung neuer Flaschenwärmer etc.). Fortlaufendes Maßnahmencontrolling, Bearbeitung von CIRS-Fällen in Regelkommunikation des QMs mit der Pflegedirektion, CIRS als Teil der Regelkommunikationen im Sicherheitsgremium sowie in der Informationssicherheit

No. Explanation
IF01

Documentation and procedural instructions for handling the error reporting system are available

As of: 22.12.2016

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 halbjährlich

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