Dealing with risks in patient care

Quality management

Inna Rifert

Leitung Regionalbereich Qualitätsmanagement und Risikomanagement

Husener Str. 46
33098 Paderborn

Phone: 05251 -702-2250
Mail: ed.nrobredap-kb@trefir.i

Inna Rifert

Leitung Regionalbereich Qualitätsmanagement und Risikomanagement

Husener Str. 46
33098 Paderborn

Phone: 05251 -702-2250
Mail: ed.nrobredap-kb@trefir.i

Medizin, Pflege, Verwaltung

Conference frequency: quartalsweise

Risk management

Inna Rifert

Leitung Regionalbereich Qualitätsmanagement und Risikomanagement

Husener Straße 46
33098 Paderborn

Phone: 05251 -702-2250
Mail: ed.nrobredap-kb@trefir.i

Inna Rifert

Leitung Regionalbereich Qualitätsmanagement und Risikomanagement

Husener Straße 46
33098 Paderborn

Phone: 05251 -702-2250
Mail: ed.nrobredap-kb@trefir.i

Medizin, Pflege, Verwaltung

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

Digitales QM-Handbuch (31.07.2023)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Notfall im Krankenhaus (31.07.2023)

RM05

Pain management

Stufenschema des Akutschmerzdienstes (31.07.2023)

RM06

Fall prophylaxis

Expertenstandard Sturzprophylaxe (31.07.2023)

RM07

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

Expertenstandard Dekubitusprophylaxe (31.07.2023)

RM08

Regulated handling of custodial measures

Prozessbeschreibung (31.12.2022)

RM09

Regulated handling of occurring malfunctions of devices

Digitales Meldesystem (31.12.2022)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Pathologiebesprechungen
  • Palliativbesprechungen
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

Prozess Time Time Out (31.12.2022)

RM15

Preoperative, complete presentation of necessary findings

Prozess Time Time Out (31.12.2022)

RM16

Procedure to avoid procedural and patient mix-ups

Prozessbeschreibung (31.12.2022)

RM17

Standards for recovery and postoperative care

Prozessbeschreibung (31.12.2022)

RM18

Discharge management

Prozessbeschreibung (31.12.2022)

Fault reporting systems

Conference committee

Conference frequency: bei Bedarf

Measures

Risikoaudits

No. Explanation
IF01

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

As of: 31.12.2022

IF02

Internal evaluation of the received reports

taken bei Bedarf

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: bei Bedarf

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)

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