Dealing with risks in patient care
Quality management
Christine Winter
Qualitätsmanagement
Graseggerstr. 105
50737 Köln
Phone:
0221
-7491-1336
Mail:
ed.nennitillec@retniw.enitsirhc
Qualitätszirkel, Qualitätsbeauftragte aus allen Abteilungen
Conference frequency: quartalsweise
Risk management
Christine Winter
Qualitäts- und Risikomanagement
Graseggerstr.
50737 Köln
Phone:
0221
-7491-1336
Fax: 0221-7491-8925
Mail:
ed.nennitillec@retniW.enitsirhC
Chef- und/oder Oberärzte der Abteilungen, Pflegedirektion, Geschäftsführer, kaufmännischer Direktor, QMB
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM-Handbuch (06.12.2021) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Durchführung und Organisation des krankenhausinternen Reanimations- und Notfallteams (28.07.2021) |
| RM05 |
Pain management Schmerzmanagement-Handbuch (27.09.2018) |
| RM06 |
Fall prophylaxis Sturzprophylaxe - Expertenstandard (06.05.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Umsetzung des Expertenstandards Dekubitusprophylaxe in der Pflege (02.01.2020) |
| RM08 |
Regulated handling of custodial measures Fixierung eines Patienten (10.09.2020) |
| RM09 |
Regulated handling of occurring malfunctions of devices Lenkung von Korrektur-, Vorbeugemaßnahmen und fehlerhaften Produkten (03.12.2020) |
| 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 Prämedikation - präoperative Standarduntersuchungen und verschiedene Checklisten (14.07.2020) |
| RM15 |
Preoperative, complete presentation of necessary findings Prämedikation - Präoperative Evaluation - Allgemein (14.07.2020) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Diverse Checklisten, Standard Patientenidentifikationsarmband, Patientensuche in ORBIS zur Vermeidung einer Patientenverwechselung, etc. (18.05.2021) |
| RM17 |
Standards for recovery and postoperative care Aufwachraum Statut (08.09.2020) |
| RM18 |
Discharge management Entlassung eines Patienten (12.02.2021) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Erstellung neuer Verfahrensanweisungen, Überarbeitung bzw. Einführung von Sicherheitschecklisten, Ergänzung der Ausstattung (z.B.: Notfallmanagement), Information/Aufklärung von Mitarbeitern (schriftlich oder über Schulungen/Veranstaltungen)
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 12.01.2021 |
| IF02 |
Internal evaluation of the received reports taken quartalsweise |
| 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 |
|---|---|
|
Other |
|
| 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 |
| EF13 |
DokuPIK (Documentation of Pharmaceutical Interventions in Hospitals at the Federal Association of German Hospital Pharmacists (ADKA) |