Dealing with risks in patient care
Quality management
Marcel Debray
Qualitäts- und Risikomanagementbeauftragter
Kunibertskloster 11-13
50668 Köln
Phone:
0221
-1629-1070
Mail:
ed.nennitillec@yarbed.lecram
Betriebsleitung, QMB, Pflege, Ärzte
Conference frequency: quartalsweise
Risk management
Marcel Debray
Qualitäts- und Risikomanagementbeauftragter
Kunibertskloster
50668 Köln
Phone:
0221
-1629-1070
Mail:
ed.nennitillec@yarbed.lecram
Betriebsleitung, QMB, Pflege, Ärzte
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitätshandbuch (24.02.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Qualitätshandbuch (29.10.2021) |
| RM05 |
Pain management Qualitätshandbuch (03.05.2022) |
| RM06 |
Fall prophylaxis Qualitätshandbuch (24.02.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Qualitätshandbuch (28.02.2020) |
| RM08 |
Regulated handling of custodial measures Qualitätshandbuch (15.06.2020) |
| RM09 |
Regulated handling of occurring malfunctions of devices Qualitätshandbuch (14.12.2021) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM13 |
Application of standardised surgical check lists |
| RM15 |
Preoperative, complete presentation of necessary findings Prozessbeschreibung Administrative Aufnahme (in Zusammenarbeit mit der KKL) (30.03.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Qualitätshandbuch (10.11.2021) |
| RM17 |
Standards for recovery and postoperative care Postoperative Anästhesiologische Anordnungen & Dokumentation für die Station (in Zusammenarbeit mit der KKL) (01.10.2020) |
| RM18 |
Discharge management Qualitätshandbuch (24.06.2020) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Einsatz von Stationsapotheker zur Erhöhung der Arzneimitteltherapiesicherheit
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 05.10.2021 |
| 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 monatlich |
Conference committee
Conference frequency: halbjährlich
| 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 |