Dealing with risks in patient care
Quality management
Dr. med. Andreas Sander
Medizinischer Geschäftsführer
Kreuzstraße 28
46535 Dinslaken
Phone:
0203
-508-1500
Mail:
ed.nlkve@fgm
- Geschäftsführung - Ärztliche Direktoren - Pflegedirektorin - Ltg. Personalabteilung - Ltg. Patientenmanagement - Ltg. Medizincontrolling - Mitarbeitervertretung - Qualitätsmanagementbeauftragter
Conference frequency: quartalsweise
Risk management
Andreas Sander
Medizinischer Geschäftsführer
Kreuzstraße 28
46535 Dinslaken
Phone:
0203
-508-1500
Mail:
ed.nlkve@fgm
- Geschäftsführung - Ärztliche Direktoren - Pflegedirektorin - Ltg. Personalabteilung - Ltg. Patientenmanagement - Ltg. Medizincontrolling - Mitarbeitervertretung - Qualitätsmanagementbeauftragter
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikomatrix (25.06.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Diverse Dokumente im Bereich der Kliniken zum Umgang mit Med. Notfällen und Komplikationen (01.01.2019) |
| RM05 |
Pain management Expertenstandard Schmerzmanagement (01.10.2022) |
| RM06 |
Fall prophylaxis Sturzprophylaxe (01.10.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitusprophylaxe (01.10.2022) |
| RM08 |
Regulated handling of custodial measures Anordnung und Durchführung von Zwangsmaßnahmen (01.06.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Organisationshandbuch MPG EVKLN (01.08.2023) |
| 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 Diverse Dokumente zur Patientenaufklärung (01.06.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings roXtra-ID: 9978 (01.04.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Einsatz von Patientenidentifikationsbändern (01.10.2022) |
| RM17 |
Standards for recovery and postoperative care Diverse Dokumente für die postoperative Versorgung vorhanden (01.08.2019) |
| RM18 |
Discharge management Entlassmanagement (01.11.2022) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Etablierung eines CIRS-Systems Etablierung von Störmeldemodulen Veränderungen von klinischen Prozessabläufen Klinikumsweite Einführung von Patientenarmbändern
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.03.2023 |
| IF02 |
Internal evaluation of the received reports taken halbjährlich |
Conference committee
Conference frequency: andere Frequenz
| 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 |