Dealing with risks in patient care
Quality management
Sascha Schrade
komm. Leitung Qualitätsmanagement
Brechtener Str. 59
44536 Lünen
Phone:
0231
-922-1061
Mail:
ed.nelaftsew-mukinilk@edarhcs.ahcsas
Sascha Schrade
komm. Leitung Qualitätsmanagement
Brechtener Str. 59
44536 Lünen
Phone:
0231
-922-1061
Mail:
ed.nelaftsew-mukinilk@edarhcs.ahcsas
Alle Kliniken, Stationen, die Hygiene sowie die technische Abteilung sind fester Bestandteil der regelmäßigen Qualitätszirkeln sowie QM-Steuergruppen.
Conference frequency: monatlich
Risk management
Sascha Schrade
komm. Leitung Qualitätsmanagement
Phone:
0231
-922-1061
Fax: 0231-922-1640
Mail:
ed.nelaftsew-mukinilk@edarhcs.ahcsas
Sascha Schrade
komm. Leitung Qualitätsmanagement
Phone:
0231
-922-1061
Fax: 0231-922-1640
Mail:
ed.nelaftsew-mukinilk@edarhcs.ahcsas
Geschäftsführung, Projektmanagement, Ärztlicher Dienst, Pflegedienstleitung, QM, Technik, Controlling, EDV
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Chancen- und Risikomanagement - SOP (26.08.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Individuell je Fachabteilung; Einsatz und Alarmierungsplan (01.07.2022) |
| RM05 |
Pain management Leitline Schmerz - VA (20.08.2022) |
| RM06 |
Fall prophylaxis Sturzprophylaxe - VA (26.08.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusprophylaxe Expertenstandard - VA (23.01.2022) |
| RM08 |
Regulated handling of custodial measures Freiheitsentziehende Maßnahmen - VA (08.05.2022) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM13 |
Application of standardised surgical check lists |
| RM16 |
Procedure to avoid procedural and patient mix-ups Vermeidung von Eingriffsverwechselung - VA (09.02.2022) |
| RM17 |
Standards for recovery and postoperative care Tätigkeiten im Aufwachraum - AA (20.08.2022) |
| RM18 |
Discharge management Individuell je Fachabteilung (26.08.2022) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
CIRS, Patientenidentifikationsarmbänder, WHO-Checkliste, Team-Time-Out, MRSA-Abstriche bei jedem Patienten, Aktion saubere Hände, Sturz und Dekubitus, Konzept zur Eingriffsverwechselung, Zertifizierte Aufbereitung der Medizinprodukte nach DIN EN 13485 (inklusive kritisch C), pflegerisches Risiko Assessment
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 30.08.2022 |
| 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 monatlich |
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 |