Dealing with risks in patient care
Quality management
B.A. Pflege- und Gesundheitsmanagement Sina Mollenhauer
Allgemeines Qualitätsmanagement
An´t Lindeken 100
48691 Vreden
Phone:
02561
-99-1750
Mail:
ed.lmwk@reuahnellom.anis
Mitglieder der KBL und QM
Conference frequency: quartalsweise
Risk management
Sina Mollenhauer
Allgemeines Qualitätsmanagement
Phone:
02561
-99-1750
Fax: 02871-20-1706
Mail:
ed.lmwk@reuahnellom.anis
Mitglieder der KBL und QM
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Teil der QM/RM Dokumentation (31.12.2021) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Teil der QM/RM Dokumentation (31.12.2021) |
| RM05 |
Pain management Teil der QM/RM Dokumentation (31.12.2021) |
| RM06 |
Fall prophylaxis Teil der QM/RM Dokumentation (31.12.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Teil der QM/RM Dokumentation (31.12.2021) |
| RM08 |
Regulated handling of custodial measures Teil der QM/RM Dokumentation (31.12.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices Teil der QM/RM Dokumentation (31.12.2021) |
| 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 Teil der QM/RM Dokumentation (31.12.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings Teil der QM/RM Dokumentation (31.12.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Teil der QM/RM Dokumentation (31.12.2021) |
| RM17 |
Standards for recovery and postoperative care Teil der QM/RM Dokumentation (31.12.2021) |
| RM18 |
Discharge management Teil der QM/RM Dokumentation (31.12.2021) |
Fault reporting systems
Conference committee
Conference frequency: andere Frequenz
Measures
- Tagungsfrequenz des Gremiums alle 8 Wochen - Anwendung von Patientenidentifikationsarmbändern - Anwendung der WHO- Sicherheitscheckliste präoperativ/ intraoperativ - Maßnahmen zur Arzneimitteltherapiesicherheit - Präsentation der Quick- Alerts im Intranet - Risikoaudits durch die Apotheke - Maßnahmenableitungen aus Befragungen (Mitarbeiter, Einweiser, Patienten) - Beschwerdemanagement - Einführung einer Endoskopie- und Herzkatheterlaborsicherheitscheckliste - Auswertung externer QS
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 31.12.2021 |
| 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 bei Bedarf |
Conference committee
Conference frequency: andere Frequenz
| 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 |