Dealing with risks in patient care

Quality management

Shirley Rasche

Qualitäts- und Risikomanagement

Bürkle-de-la-Camp-Platz 1
44789 Bochum

Phone: 0234 -302-6118
Mail: ed.liehsnnamgreb@ehcsar.yelrihs

Geschäftsführung/ Verwaltungsdirektorin, Pflegedirektion, Ärztliche Direktion, Leiter Medizinmanagement , Qualitäts- und Risikomanagement

Conference frequency: jährlich

Risk management

Shirley Rasche

Qualitäts- und Risikomanagement


44702 Bochum

Phone: 0234 -302-6118
Fax: 0234-302-6200
Mail: ed.liehsnnamgreb@ehcsar.yelrihs

Geschäftsführung/ Verwaltungsdirektorin, Pflegedirektion, Ärztliche Direktion, Leiter Medizinmanagement , Qualitäts- und Risikomanagement

Conference frequency: jährlich

Risk management instruments and measures

No. Explanation
RM01

Comprehensive quality and/or risk management documentation (QM/RM documentation) is available

Konzept zur Umsetzung des Qualitäts- und Risikomanagements (01.11.2023)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

VA Notfallmanagement (15.12.2023)

RM05

Pain management

Handbuch Akutschmerztherapie (15.05.2023)

RM06

Fall prophylaxis

Klinikbezogene Umsetzung des Expertenstandards Sturzprophylaxe (01.10.2023)

RM07

Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”)

Klinikinterne Umsetzung des Expertenstandards Dekubitusprophylaxe (10.03.2023)

RM08

Regulated handling of custodial measures

VA Freiheitsentziehende Maßnahmen (17.11.2023)

RM09

Regulated handling of occurring malfunctions of devices

Ausfallkonzepte (07.12.2023)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Pathologiebesprechungen
  • Palliativbesprechungen
  • Qualitätszirkel
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

Konzept zur Umsetzung des Qualitäts- und Risikomanagements (01.11.2023)

RM15

Preoperative, complete presentation of necessary findings

Konzept zur Umsetzung des Qualitäts- und Risikomanagements (01.11.2023)

RM16

Procedure to avoid procedural and patient mix-ups

Konzept zur Umsetzung des Qualitäts- und Risikomanagements (01.11.2023)

RM17

Standards for recovery and postoperative care

SOP AWR (28.09.2023)

RM18

Discharge management

VA Entlassmanagement (02.10.2023)

Fault reporting systems

Conference committee

Conference frequency: halbjährlich

Measures

Kontinuierliches Maßnahmenmanagement

No. Explanation
IF01

Documentation and procedural instructions for handling the error reporting system are available

As of: 01.03.2023

IF02

Internal evaluation of the received reports

taken bei Bedarf

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: 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)