Dealing with risks in patient care
Quality management
Thomas Rötterink
Qualitätsmanagement
Albert-Schweitzer-Str. 10
48527 Nordhorn
Phone:
05921
-84-1100
Mail:
ed.kinilk-oigerue@kniretteoR.samohT
Management-Steuerungsgruppe, Mitglieder: Geschäftsführung, Ärztliche Leitung, Pflegedirektion, Leitung Hygienemanagement, Leitung Qualitätsmanagement
Conference frequency: quartalsweise
Risk management
Thomas Rötterink
Qualitätsmanagement
Albert-Schweitzer-Str. 10
48527 Nordhorn
Phone:
05921
-84-1100
Fax: 05921-84-1519
Mail:
ed.kinilk-oigerue@kniretteoR.samohT
Management-Steuerungsgruppe, Mitglieder: Geschäftsführung, Ärztliche Leitung, Pflegedirektion, Leitung Hygienemanagement, Leitung Qualitätsmanagement
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Richtlinie Risikomanagement (18.12.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management PB Internes medizinisches Notfallmanagement PB Externes Notfallmanagement PB Meldewesen (20.03.2020) |
| RM05 |
Pain management Schmerzkonzept (27.03.2020) |
| RM06 |
Fall prophylaxis Expertenstandard Sturz (19.03.2020) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitusprophylaxe (19.03.2020) |
| RM08 |
Regulated handling of custodial measures Dienstanweisung Fixierung (11.03.2020) |
| RM09 |
Regulated handling of occurring malfunctions of devices Medizintechnik Handbuch (30.08.2021) |
| 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 Dienstanweisung OP-Statut (31.03.2020) |
| RM15 |
Preoperative, complete presentation of necessary findings PB Visite (31.01.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups PB Patientenidentifikation und PB Patientenarmbänder, zzgl. Team-Time-Out (19.09.2024) |
| RM17 |
Standards for recovery and postoperative care Anästhesieleitlinie (01.02.2019) |
| RM18 |
Discharge management PB Entlassmanagement (25.03.2022) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
z.B. Verwechslung von unterschiedlichen Kathetern- und Portzugängen wird durch farbliche Kennzeichnung vermieden, Verwechslung von Sauerstoff- und Inhalationsanschluss wird durch Informationsschreiben vermieden, Verwechslung von Patientendaten / Befundmaterial im OP aufgrund eines zentralen Drucker wird durch Beschaffung dezentraler Drucker pro OP-Saal vermieden, Schulungs- und Sensibilisierungsmaßnahmen zu unterschiedlichen Themen, weitere diverse präventive Maßnahmen zur Fehlervermeidung.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 02.08.2022 |
| 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: bei Bedarf
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |