Dealing with risks in patient care
Quality management
Dr. med. Michaela Gross
Leitung Abt. Qualitätsmanagement
Johannesstraße 9-13
44137 Dortmund
Phone:
0231
-1843-31050
Mail:
ed.dnumtrod-ohoj@mq
Abteilungsleitersitzung auf Trägerebene - Matrixorganisation (2-wöchentliche Sitzung) Klinikleitungskonferenz auf Trägerebene (2-monatliche Sitzung) Betriebsleitungssitzungen (monatliche Sitzung)
Conference frequency: monatlich
Risk management
Michaela Gross
Leitung Abt. Qualitätsmanagement
44047 Dortmund
Phone:
0231
-1843-31050
Fax: 0231-1843-31019
Mail:
ed.dnumtrod-ohoj@mq
Abteilungsleitersitzung auf Trägerebene - Matrixorganisation (2-wöchentliche Sitzung) Klinikleitungskonferenz auf Trägerebene (2-monatliche Sitzung) Betriebsleitungssitzungen (monatliche Sitzung)
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Intranet (02.05.2022) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Intranet (02.05.2022) |
| RM05 |
Pain management Intranet (02.05.2022) |
| RM06 |
Fall prophylaxis Intranet (02.05.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Intranet (02.05.2022) |
| RM08 |
Regulated handling of custodial measures Intranet (02.05.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Intranet (02.05.2022) |
| 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 Intranet (02.05.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings Intranet (02.05.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Intranet (02.05.2022) |
| RM17 |
Standards for recovery and postoperative care Intranet (02.05.2022) |
| RM18 |
Discharge management Intranet (02.05.2022) |
Fault reporting systems
Conference committee
Conference frequency: halbjährlich
Measures
Maßnahmen zur Vermeidung von Verwechslungen, Identifikationsarmbänder, Anwendung zahlreicher Checklisten, Schulungen aller am Patienten tätigen Mitarbeiter
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 30.11.2022 |
| 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 jährlich |
Conference committee
Conference frequency: halbjährlich
| No. | Explanation |
|---|---|
| EF01 |
CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association) |
| EF02 |
CIRS Berlin (Berlin Medical Association, German Medical Association) |
| 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) |
| EF08 |
CIRS Emergency Medicine (Department of Anaesthesia, Intensive Care Medicine and Emergency Medicine, Kempten Hospital) |
| EF13 |
DokuPIK (Documentation of Pharmaceutical Interventions in Hospitals at the Federal Association of German Hospital Pharmacists (ADKA) |
| EF17 |
DGHO-CIRS (German Society for Haematology and Medical Oncology) |