Dealing with risks in patient care

Quality management

Renardo Schiffer

Geschäftsführer

Renkerstraße 45
52355 Düren

Phone: 02421 -599-851
Mail: ed.tsew-tc@reffihcs.odraner

Geschäftsführer, Ärztlicher Direktor, Pflegedirektor, Chefarzt Innere Medizin, Qualitätsmanagementbeauftragter, Mitarbeitervertretung

Conference frequency: quartalsweise

Risk management

Renardo Schiffer

Geschäftsführer

Renkerstraße 45
52333 Düren

Phone: 02421 -599-851
Fax: 02421-599-964
Mail: ed.tsew-tc@reffihcs.odraner

Geschäftsführer, Ärztlicher Direktor, Pflegedirektor, Chefarzt Innere Medizin, Qualitätsmanagementbeauftragter, Mitarbeitervertretung

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

Elektronisches QM- und RM - Handbuch (14.09.2020)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Elektronisches QM-und RM - Handbuch (14.09.2020)

RM05

Pain management

Elektronisches QM-und RM - Handbuch (14.09.2020)

RM06

Fall prophylaxis

Elektronisches QM-und RM - Handbuch (14.09.2020)

RM07

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

Elektronisches QM-und RM - Handbuch (14.09.2020)

RM08

Regulated handling of custodial measures

Elektronisches QM-und RM - Handbuch (14.09.2020)

RM09

Regulated handling of occurring malfunctions of devices

Elektronisches QM-und RM - Handbuch (14.09.2020)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • 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

Elektronisches QM-und RM - Handbuch (14.09.2020)

RM15

Preoperative, complete presentation of necessary findings

Elektronisches QM-und RM - Handbuch (14.09.2020)

RM16

Procedure to avoid procedural and patient mix-ups

Elektronisches QM-und RM - Handbuch (14.09.2020)

RM17

Standards for recovery and postoperative care

Elektronisches QM-und RM - Handbuch (14.09.2020)

RM18

Discharge management

Elektronisches QM-und RM - Handbuch (14.09.2020)

Fault reporting systems

Conference committee

Conference frequency: quartalsweise

Measures

Einführung eines Fehlermeldesystems (CIRS). Das Fehlermeldesystem ist für alle Mitarbeiter zugänglich und einfach zu bewerkstelligen. Die Meldungen können freiwillig, anonym und sanktionsfrei durch die Mitarbeiter erfolgen. Analysen und Präventionsmaßnahmen werden zeitnah abgeleitet und umgesetzt.

No. Explanation
IF01

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

As of: 07.09.2011

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 quartalsweise

Conference committee

Conference frequency: quartalsweise

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)