Dealing with risks in patient care
Quality management
Svenja Görtz
Qualitäts- und Risikomanagement
Albersallee 5-7
47533 Kleve
Phone:
02821
-490-1265
Mail:
ed.elkk@ztreog.ajnevs
Die übergeordnete Qualitäts-und Risikodokumentation ist in der Unternehmenspolitik sowie der Risikopolitik beschrieben. Miglieder: Betriebsleitung, Qualitäts-und Risikobeauftragte der Fachabteilungen
Conference frequency: quartalsweise
Risk management
Svenja Görtz
Qualitäts- und Risikomanagement
Phone:
02821
-490-1265
Fax: 02821-490-1257
Mail:
ed.elkk@ztreog.ajnevs
Es besteht eine CIRS-Gruppe aus der Betriebsleitung, Qualitäts-und Risikobeauftragte aus unterschiedlichen Fachabteilungen und Berufsgruppen aus allen Standorten.
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitäts- und Risikopolitik (01.09.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Notfallmanagement, Notfallstatut (16.07.2022) |
| RM05 |
Pain management Schmerzmanagement (16.07.2022) |
| RM06 |
Fall prophylaxis Expertenstandard Sturz (16.07.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitusprophylaxe (16.07.2022) |
| RM08 |
Regulated handling of custodial measures Freiheitsentziehende Maßnahmen (16.07.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Medizinproduktemanagement (16.07.2021) |
| 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 OP-Statut, Verfahrensanweisungen, Team-Time-Out Checklisten (16.07.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings OP-Statut, Verfahrensanweisungen, Checklisten (16.07.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Prä- und Intraoperative Checklisten, Patientenidentifikationsarmbänder, Team-Time-Out (16.07.2022) |
| RM17 |
Standards for recovery and postoperative care Verfahrensanweisungen Aufwachraum, Überwachungs-Verlegungsdokumentation (16.07.2022) |
| RM18 |
Discharge management Entlassmanagement nach dem Expertenstandard Entlassung, sowie Umsetzung § 39 Absatz 1a SGB V (16.07.2022) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Patientenidentifikationsarmbänder Präoperative Checklisten Intraoperative Checklisten Team Time Out Checklisten bei Übergabe von Patienten in den OP-Bereich Sturzprävention Arzneimitteltherapiesicherheit elektronisch, AiDKlinik® Risikomatrix, Risikobewertung Aufklärung in verschiedenen Sprachen Medizinproduktemanagement Antibiotic Stewardship-Team
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 16.07.2022 |
| 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: halbjährlich
| 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) |
| 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 |
| EF08 |
CIRS Emergency Medicine (Department of Anaesthesia, Intensive Care Medicine and Emergency Medicine, Kempten Hospital) |
| EF10 |
CIRS of the German Society of Surgery (DGCH) |
| EF17 |
DGHO-CIRS (German Society for Haematology and Medical Oncology) |