Dealing with risks in patient care

Quality management

M.A. Henning Eichhorst

Geschäftsführer

Am Stein 24
58706 Menden

Phone: 02371 -212-114
Mail: ed.kmikk@ofni

Die Steuerungsgruppe besteht aus der Krankenhausleitung (ärztlicher Direktor, Pflegedirektor und Klinikmanager) und den Qualitätsmanagementbeauftragten.

Conference frequency: monatlich

Risk management

Henning Eichhorst

Geschäftsführer

Am Stein 24
58706 Menden

Phone: 02371 -212-114
Mail: ed.kmikk@ofni

Die Steuerungsgruppe besteht aus der Krankenhausleitung (ärztlicher Direktor, Pflegedirektor und Klinikmanager) und den Qualitätsmanagementbeauftragten.

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

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

QM-Handbuch (09.02.2023)

RM02

Regular further education and training measures

RM04

Clinical emergency management

QM-Handbuch (09.02.2023)

RM05

Pain management

QM-Handbuch (11.08.2023)

RM06

Fall prophylaxis

QM-Handbuch (17.10.2023)

RM07

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

QM-Handbuch (17.10.2023)

RM08

Regulated handling of custodial measures

QM-Handbuch (06.07.2021)

RM09

Regulated handling of occurring malfunctions of devices

QM-Handbuch (14.07.2022)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
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

QM-Handbuch (08.11.2022)

RM15

Preoperative, complete presentation of necessary findings

QM-Handbuch (08.11.2022)

RM16

Procedure to avoid procedural and patient mix-ups

QM-Handbuch (09.02.2023)

RM17

Standards for recovery and postoperative care

QM-Handbuch (08.11.2023)

RM18

Discharge management

QM-Handbuch (11.08.2023)

Fault reporting systems

Conference committee

Conference frequency: bei Bedarf

Measures

u.a. fortlaufendes Abfragen der Patientenidentität um Verwechslungen vorzubeugen

No. Explanation
IF01

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

As of: 09.02.2023

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 bei Bedarf

Conference committee

Conference frequency: bei Bedarf

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