Dealing with risks in patient care

Quality management

Herr Mateusz Bochenek

Qualitätsmanagementbeauftragter

Klosterstrasse 32
40764 Langenfeld

Phone: 02173 -796-8511
Mail: ed.enilno-ofg@kenehcob.zsuetam

Herr Mateusz Bochenek

Qualitätsmanagementbeauftragter

Klosterstrasse 32
40764 Langenfeld

Phone: 02173 -796-8511
Mail: ed.enilno-ofg@kenehcob.zsuetam

Ärztlicher Direktor, Kaufmänner Direktor, Pflegedirektorin und QMB

Conference frequency: halbjährlich

Risk management

Mateusz Bochenek

Qualitätsmanagementbeauftragter


40764 Langenfeld

Phone: 02173 -796-8511
Fax: 02173-796-218
Mail: ed.enilno-ofg@kenehcob.zsuetam

Mateusz Bochenek

Qualitätsmanagementbeauftragter


40764 Langenfeld

Phone: 02173 -796-8511
Fax: 02173-796-218
Mail: ed.enilno-ofg@kenehcob.zsuetam

Das Team des klinischen Risikomanagements tagt alle sechs Wochen, mindestens jedoch einmal in drei Monaten.

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

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

Organisationshandbuch (14.07.2023)

RM02

Regular further education and training measures

RM04

Clinical emergency management

Organisationshandbuch (14.07.2023)

RM05

Pain management

Organisationshandbuch (14.07.2023)

RM06

Fall prophylaxis

Standard Sturzprophylaxe (14.10.2009)

RM07

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

Standard Dekubitusprophylaxe (16.12.2019)

RM08

Regulated handling of custodial measures

Verfahrensanweisung (21.06.2022)

RM09

Regulated handling of occurring malfunctions of devices

Organisationshandbuch (14.07.2023)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Mortalitäts- und Morbiditätskonferenzen
  • Qualitätszirkel
RM12

Use of standardised information sheets

RM13

Application of standardised surgical check lists

RM16

Procedure to avoid procedural and patient mix-ups

Organisationshandbuch (14.07.2023)

RM17

Standards for recovery and postoperative care

Anästhesiestandards (09.05.2022)

RM18

Discharge management

Über das KIS seit (01.10.2017)

Fault reporting systems

Conference committee

Conference frequency: quartalsweise

Measures

Etablierung einer prozessorientierten Risikoanalyse.

No. Explanation
IF01

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

As of: 11.07.2022

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
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