Dealing with risks in patient care
Quality management
Martina Niemeier
Abteilungsleitung Medizincontrolling/Zentrale Leistungsabrechnung/Qualitätsmanagement
Paulmannshöher Straße 17
58515 Lüdenscheid
Phone:
02351
-945-2224
Mail:
ed.nesrelleh@mq
Vorstand, QMB, PDL, Chefärzte, Ärztliche Direktorin
Conference frequency: monatlich
Risk management
Petra Scheffer
Ärztliche Direktorin/Chefärztin Plastische, Rekonstruktive und Ästhetische Chirurgie/Handchirurgie
58505 Lüdenscheid
Phone:
02351
-945-2228
Fax: 02351-945-2097
Mail:
ed.nesrelleh@reffehcs.tairaterkes
Vorstand, Ärztliche Direktorin, QMB, PDL, Chefärzte
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available VA Fehlermanagement/Risikomanagement (31.08.2023) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management VA Fehlermanagement/Risikomanagement (31.08.2023) |
| RM05 |
Pain management VA Fehlermanagement/Risikomanagement (31.08.2023) |
| RM06 |
Fall prophylaxis VA Fehlermanagement/Risikomanagement (31.08.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) VA Fehlermanagement/Risikomanagement (31.08.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices VA Fehlermanagement/Risikomanagement (31.08.2023) |
| 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 VA Fehlermanagement/Risikomanagement (31.08.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings VA Fehlermanagement/Risikomanagement (31.08.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups VA Fehlermanagement/Risikomanagement (31.08.2023) |
| RM18 |
Discharge management VA Fehlermanagement/Risikomanagement (31.08.2023) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Im Rahmen von regelmäßgien QM-Besprechungen werden eingegangene Meldungen analysiert, bewertet und Maßnahmen eingeleitet mit einer späteren Evaulation (PDCA-Zyklus)
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 31.08.2023 |
| IF02 |
Internal evaluation of the received reports taken monatlich |
| 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: