Dealing with risks in patient care
Quality management
Regina Rommel
Qualitätsmanagement Koordinatorin
Bremer Straße 31
49179 Ostercappeln
Phone:
05473
-29-912
Mail:
ed.nekinilk-nesnets-slein@lemmor.aniger
Geschäftsführung, Verwaltungsdirektor, Pflegedirektor, Ärztlicher Direktor, Krankenhausoberin
Conference frequency: monatlich
Risk management
Regina Rommel
Qualitätsmanagement Koordinatorin
Bremer Straße 31
49179 Ostercappeln
Phone:
05473
-29-912
Fax: 05473-29-247
Mail:
ed.nekinilk-nesnets-slein@lemmor.aniger
entspricht den Angaben zum Qualitätsmanagement
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikomanagement Handbuch Niels-Stensen-Kliniken, Dokumentennummer 016369 (23.11.2023) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Dok. 2674 Notfallmanagement Zuständigkeit und Organisation (31.08.2022) |
| RM05 |
Pain management Dok. 4684 Leitlinie Akutschmerztherapie (28.04.2020) |
| RM06 |
Fall prophylaxis Standard Sturzprophylaxe Ratgeber zur Vermeidung von Stürzen im Krankenhaus (14.05.2024) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Standard zur Dekubitusprophylaxe (11.12.2023) |
| RM08 |
Regulated handling of custodial measures Dok. 14967 Freiheitsentziehende Maßnahmen (11.09.2023) |
| 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-Checkliste, Team Time out (21.09.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings OP-Checkliste, Team Time out (27.08.2024) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Diverse Regelungen in den QM-Dokumenten der einzelnen Abteilungen, OP- Seitenmarkierung, OP- Seitenangabe in sämtlichen Planungsdokumenten zur OP (Terminplan, OP- Plan, …), Patientenarmbänder, usw. (16.02.2018) |
| RM17 |
Standards for recovery and postoperative care Konzept Aufwachraum, OP- Statut (13.02.2024) |
| RM18 |
Discharge management Diverse Dokumente, die das Entlassungsmanagement regeln, VA Entlassmanagement (20.02.2019) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
OP-Sicherheitscheckliste, Patientenidentifikationsarmband, Team-Time-Out im OP, im Hygienebereich Sreening auf multiresistente Keime, anonymes Meldesystem für Beinahe-Fehler und Risiken, regelmäßige Begehungen durch interne und externe Sachverständige
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 26.08.2024 |
| 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 bei Bedarf |
Conference committee
Conference frequency: quartalsweise
| No. | Explanation |
|---|---|
|
Other |