Dealing with risks in patient care
Quality management
Dr. Hubert Buddendick
Leitbildbeauftragter - Leiter Qualitätsmanagement
Hohenzollernring 70
48145 Münster
Phone:
0251
-935-3841
Mail:
ed.retsneum-hfs@mq
- Projektsteuerungsgruppe: Lenkungs- u. Entscheidungsorgan der Leitbildumsetzung im Hospital (Steuerung von Projekten) - Transferkreis: hospitalübergreifenden Erfahrungsaustausch zw. den Leitbildbeauftragten (Qualitätsbeauftragten) der Stiftungshäuser
Conference frequency: andere Frequenz
Risk management
Ursula Grewing
Stellvertretende Leitung Qualitätsmanagement
48136 Münster
Phone:
0251
-935-3869
Fax: 0251-935-3637
Mail:
ed.retsneum-hfs@mq
- Projektsteuerungsgruppe: Lenkungs- u. Entscheidungsorgan der Leitbildumsetzung im Hospital (Steuerung von Projekten) - Transferkreis: hospitalübergreifenden Erfahrungsaustausch zw. den Leitbildbeauftragten (Qualitätsbeauftragten) der Stiftungshäuser
Conference frequency: andere Frequenz
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Handbuch Qualitätsmanagement (06.05.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Notfallmanangement/ Reanimation (28.04.2022) |
| RM05 |
Pain management Handbuch Schmerztherapie (07.01.2021) |
| RM06 |
Fall prophylaxis Expertenstandard Sturzprophylaxe (05.05.2020) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitusprophylaxe (28.01.2020) |
| RM08 |
Regulated handling of custodial measures Richtlinie zur Fixierung eines Patienten (27.06.2020) |
| RM09 |
Regulated handling of occurring malfunctions of devices Arbeiten an Medizingeräten (Firma Fact) (12.04.2020) |
| 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 Tumorkonferenzen Präoperativ (04.10.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Patientenarmbänder - Management Patientensicherheit (04.10.2022) |
| RM17 |
Standards for recovery and postoperative care Betreuung im Aufwachraum (04.10.2022) |
| RM18 |
Discharge management Entlassmanagement (24.08.2022) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
- Aktive Beschäftigung mit gemeldeten Fällen - Sensibilisierung der Mitarbeiter zum Umgang mit Fehlern - Veränderung zur Medikamentenlagerung - Aktualisierungen / Anpassungen von Verfahrensanweisungen -Etablierung eines Simulationszentrums
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 08.03.2022 |
| IF02 |
Internal evaluation of the received reports taken jährlich |
| 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: andere Frequenz
| 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) |
| 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 |