Dealing with risks in patient care
Quality management
Dipl. -Oek/Medizin (FH) Manuela Seegers
Klinikleitung
Hafenstraße 68-76
41460 Neuss
Phone:
02131
-2695-1005
Mail:
ed.mukinilkdnalniehr@kinilkrotniehr
1. Abt. Betrieb, Qualitäts- und klinisches Risikomanagement. Justiziariat, Pflegedienstleitung, IT 2. zusätzlich noch innerhalb des Hauses im Rahmen des EPZ
Conference frequency: monatlich
Risk management
1. Abt. Betrieb, Qualitäts- und klinisches Risikomanagement. Justiziariat, Pflegedienstleitung, IT 2. zusätzlich noch innerhalb des Hauses im Rahmen des EPZ
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Verfahrensanweisung Dokumentenlenkung (15.01.2020) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management VA Notfallmanagement (12.01.2021) |
| RM05 |
Pain management Schmerzstandard Ia-c, Ia-c, IIIa-c (20.02.2021) |
| RM06 |
Fall prophylaxis Handlungsempfehlung Sturzprophylaxe (01.12.2018) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) zurzeit in Erstellung noch nicht verabschiedet (31.12.2015) |
| RM08 |
Regulated handling of custodial measures Handlungsanweisung 6. Version Segufix Fixierung (01.12.2018) |
| RM09 |
Regulated handling of occurring malfunctions of devices Störungsmeldung V1.0 (23.10.2019) |
| 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 Anästhesie Prä OP Bögen, Checkliste OP-Vorbereitung (01.05.2017) |
| RM15 |
Preoperative, complete presentation of necessary findings SOP Indikationsbesprechung, Checkliste OP-Vorbereitung (14.11.2020) |
| RM16 |
Procedure to avoid procedural and patient mix-ups WHO-Checkliste Patientensicherheit, VA zum Patientenidentifikationsarmband (01.05.2017) |
| RM17 |
Standards for recovery and postoperative care OP-Protkoll/ Behandlungspfad HüftTEP/ Behandlungspfad KnieTEP (23.11.2021) |
| RM18 |
Discharge management SOP Entlassungmanagement (14.01.2020) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Durch eine CIRS-Meldung wurde eine potentielle Schwachstelle erkannt => Laboreingabe im KIS (Krankenhausinformationssystem) erfolgt nun immer im aktuellen Fall.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.02.2019 |
| 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: quartalsweise
| 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 |