Dealing with risks in patient care
Quality management
Uwe Petersen
Regionalleitung Qualitätsmanagement Nordrhein-Westfalen / Qualitäts-/klin. Risikomanagement Sana-Klinikum Remscheid
Burger Straße 211
42859 Remscheid
Phone:
02191
-13-3013
Mail:
ed.anas@nesretep.ewu
Geschäftsführung, Ärztliche Direktion, Pflegedirektion
Conference frequency: monatlich
Risk management
Uwe Petersen
Regionalleitung QM und klinisches Risikomanagement NRW
Phone:
02191
-13-3013
Fax: 02191-13-3029
Mail:
ed.anas@nesretep.ewu
Geschäftsführerin, Klinikmanager, Ärztlicher Direktor, Pflegedirektorin, Regionalleiter NRW Qualitätsmanagement/Risikomanagement
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available DOK Klinisches Fehler- und Risikomanagement-Nichterfüllung (12.11.2020) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management VA Umgang mit Notfallkoffern, VA Notfallteam (16.03.2020) |
| RM05 |
Pain management Konzept perioperative Schmerztherapie (21.04.2020) |
| RM06 |
Fall prophylaxis VA Sturzmanagement (26.07.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) VA Dekubitusprophylaxe (27.09.2021) |
| RM08 |
Regulated handling of custodial measures VA Fixierung; VA Kriseninterventionsbereich ZSG (21.05.2019) |
| RM09 |
Regulated handling of occurring malfunctions of devices Samba-Handbuch (30.08.2021) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM13 |
Application of standardised surgical check lists |
| RM14 |
Preoperative summary of predictable critical surgical steps, surgical time and expected blood loss VA OP-Organisation im Regelbetrieb (30.08.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings VA OP-Organisation im Regelbetrieb (30.08.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups OP-Sicherheitscheckliste, VA Patientenidentifikationsarmband (27.08.2021) |
| RM17 |
Standards for recovery and postoperative care VA Aufwachraum; VA Ruheraum-Diagnostikzentrum (27.07.2021) |
| RM18 |
Discharge management VA Entlassmanagement (23.08.2021) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Hygienebegehungen, unvermutete Begehungen verschiedener Behörden, aktive Fallanalysen nach London Protokoll, Durchführung von externen und internen Risikoaudits nach Risikopräventionskatalog, Durchführung interner Audits, Dokumentationsaudits, Anpassungen im Kontext Arzneimitteltherapiesicherheit, Auseinandersetzung mit den Erkenntnissen aus Quick Alerts und übergeordneten CIRS-Meldungen u. a.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 06.07.2020 |
| IF02 |
Internal evaluation of the received reports taken quartalsweise |
| IF03 |
Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken quartalsweise |
Conference committee
Conference frequency: quartalsweise
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors) |