Dealing with risks in patient care
Quality management
Diplompflegewirtin Monika Ossig
Qualitätsmanagement
Reckenberger Str. 19
33332 Gütersloh
Phone:
05241
-8325116-
Mail:
ed.holsreteug-mukinilk@gisso.akinom
Betriebsleitung inkl. Beteiligung QM
Conference frequency: monatlich
Risk management
Betriebsleitung inkl. Beteiligung QM
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikomanagement-Konzept (10.04.2021) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Medizinischer Notfall (21.06.2022) |
| RM05 |
Pain management Schmerzmanagement Klinikum Gütersloh (12.05.2023) |
| RM06 |
Fall prophylaxis Sturzprophylaxe (27.06.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusprophylaxe (18.06.2021) |
| RM08 |
Regulated handling of custodial measures Fixierungsmaßnahmen (18.06.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices Dienstanweisung Medizinprodukte (20.12.2017) |
| 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 Risikomanagement-Konzept (10.04.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings Risikomanagement-Konzept (10.04.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Eingriffsverwechslung (27.03.2019) |
| RM17 |
Standards for recovery and postoperative care Aufgaben im Aufwachraum und Einarbeitungsleitfaden ÄD Intensivstation (04.10.2021) |
| RM18 |
Discharge management Entlassmanagement (10.06.2023) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Prozesse wurden umgestellt, Patientensicherheitsarmbänder, Team Time Out, Umstellung von Medikamenten (Look a Like Problematik), Anschaffung von gleichen Infusiomaten etc.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 30.06.2021 |
| 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 |
|---|---|
| EF01 |
CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association, National Association of Statutory Health Insurance Doctors) |
| 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 |
| EF14 |
CIRS Health Care |
| EF17 |
DGHO-CIRS (German Society for Haematology and Medical Oncology) |