Dealing with risks in patient care
Quality management
Herr J. Weissinger
Qualitätsmanagementbeaufragter
Dorbaumstraße 300
48157 Münster
Phone:
0251
-3287-392
Mail:
ed.ediehnroh-kinilkhcaf@regnissiew.snej
Krankenhausdirektor, Leiter Hauttumorzentrum, Leiter Kopf-Hals-Tumor-Zentrum, Zentrumskoordinatoren, Qualitätsmanagementbeauftragte
Conference frequency: monatlich
Risk management
M. Maas
Chefarzt Anästhesie, Intensivmedizin und Schmerztherapie
Phone:
0251
-3287-487
Fax: 0251-3287-6037
Mail:
ed.ediehnroh-kinilkhcaf@saam.saihttam
Chefarzt Anästhesie, Pflegebereichsleitungen, Stationsleitungen, Qualitätsmanagement
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2021) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2021) |
| RM05 |
Pain management QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2021) |
| RM06 |
Fall prophylaxis QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2021) |
| RM08 |
Regulated handling of custodial measures QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2021) |
| 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 QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2021) |
| RM17 |
Standards for recovery and postoperative care QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2021) |
| RM18 |
Discharge management QM-Dokumentation für das Hauttumorzentrum und Kopf-Hals-Tumor-Zentrum (01.08.2021) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Risikobewertung der Prozesse vor dem Hintergrund der DSGVO ,Optimierung der OP-Sicherheitscheckliste, Optimierung der Arzneimitteltherapiesicherheit, regelmäßige ABS Visiten
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 08.10.2020 |
| 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 jährlich |
Conference committee
Conference frequency: jährlich
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors) |
| 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 |