Dealing with risks in patient care

Quality management

Dorothee Hardenbicker

Qualitätsmanagementbeauftragte

Hospitalweg 6
57462 Olpe

Phone: 02761 -85-2158
Mail: ed.enilno-ofg@rekcibnedrah.eehtorod

Dorothee Hardenbicker

Qualitätsmanagementbeauftragte

Hospitalweg 6
57462 Olpe

Phone: 02761 -85-2158
Mail: ed.enilno-ofg@rekcibnedrah.eehtorod

Betriebsleitung

Conference frequency: monatlich

Risk management

Dorothee Hardenbicker

Qualitätsmanagementbeauftragte

Hospitalweg 6
57462 Olpe

Phone: 02761 -85-2158
Fax: 02761-85-2800
Mail: ed.enilno-ofg@rekcibnedrah.eehtorod

Dorothee Hardenbicker

Qualitätsmanagementbeauftragte

Hospitalweg 6
57462 Olpe

Phone: 02761 -85-2158
Fax: 02761-85-2800
Mail: ed.enilno-ofg@rekcibnedrah.eehtorod

Das Zentrales CIRS-Team (interprofessionelle Zusammensetzung) wird durch die Mitarbeiter:innen des Qualitätsmanagements moderiert

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

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

Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)

RM02

Regular further education and training measures

RM04

Clinical emergency management

Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)

RM05

Pain management

Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)

RM06

Fall prophylaxis

Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)

RM07

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

Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)

RM08

Regulated handling of custodial measures

Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)

RM09

Regulated handling of occurring malfunctions of devices

Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Palliativbesprechungen
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

Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)

RM15

Preoperative, complete presentation of necessary findings

Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)

RM16

Procedure to avoid procedural and patient mix-ups

Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)

RM17

Standards for recovery and postoperative care

Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)

RM18

Discharge management

Organisationshandbuch der GFO Kliniken Südwestfalen (21.02.2023)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

strukturiertes Fehlermanagement nach den Vorgaben der DIN EN ISO 9001:2015 etabliert

No. Explanation
IF01

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

As of: 21.02.2023

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: monatlich

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