Dealing with risks in patient care
Quality management
Lukas Matyschik
Qualitätsmanagementleitung
Clemensstraße 6
47608 Geldern
Phone:
02831
-390-1401
Mail:
ed.latipsoh-snemelc@kihcsytam.l
Ärztliche Direktion, Klinikdirektor, Pflegedirektion, Mitarbeitervertretung, Seelsorge, Qualitätsmanagementbeauftragte,
Conference frequency: quartalsweise
Risk management
Lukas Matyschik
Qualitätsmanagementleitung
Phone:
02831
-390-1401
Fax: 02831-390-3000
Mail:
ed.latipsoh-snemelc@kihcsytam.l
Ärztlicher Direktor, Klinikdirektor, Pflegedirektor, Chefärzte, Stations- bzw. Funktionsleitungen, Qualitätsmanagementbeauftragte,
Conference frequency: andere Frequenz
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available 2.0.1.03. Risikomanagement (01.08.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management 2.0.0.80.01. Notfallmanagement (01.12.2020) |
| RM05 |
Pain management 13.2.9.3.1. Schmerztherapie Post-OP (01.09.2021) |
| RM06 |
Fall prophylaxis 4.0.1.06. Sturzmanagement / Pflegestandard Sturzprophylaxe (01.09.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) 4.0.1.07. Dekubitusmanagement (01.10.2023) |
| RM08 |
Regulated handling of custodial measures 5.0.1.09. Freiheitsentziehende Maßnahmen (01.10.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices 2.0.0.13. Umsetzung Medizinproduktegesetz (MPG), Medizinprodukte-Betreiberverordnung (MPBetreibV) und Medizinprodukte Sicherheitsplanverordnung (MPSV)3.9.1.05. Sicherheits- und messt. Kontrollen (01.03.2020) |
| 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 2.0.0.16. Patientensicherheit-Richtiger Patient/Richtiger Eingriff (19.06.2019) |
| RM15 |
Preoperative, complete presentation of necessary findings 2.0.0.16. Patientensicherheit-Richtiger Patient/Richtiger Eingriff (19.06.2019) |
| RM16 |
Procedure to avoid procedural and patient mix-ups 2.0.0.16. Patientensicherheit -Richtiger Patient/Richtiger Eingriff (19.06.2019) |
| RM17 |
Standards for recovery and postoperative care 5.0.1.27. Postoperative Versorgung (01.09.2023) |
| RM18 |
Discharge management 2.0.0.90 Entlassmanagement (17.12.2020) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Z.B. Optimierung der Maßnahmen gegen Verwechslungsgefahr von Laborproben, Verbesserung des Datenschutzes im Umgang mit Gastpersonal, Optimierung des Triage-Systems in der Zentralen Notfallaufnahme
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 07.09.2023 |
| IF02 |
Internal evaluation of the received reports taken monatlich |
Conference committee
Conference frequency: monatlich
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |
| EF06 |
CIRS NRW (North Rhine and Westphalia-Lippe Medical Associations, North Rhine-Westphalia Hospital Association, North Rhine and Westphalia-Lippe Associations of Statutory Health Insurance Physicians, German Medical Association) |