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
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

Jahres CIRS-Auswertung (02.10.2023)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Notfallmanagement (02.10.2023)

RM05

Pain management

Handbuch Akutschmerztherapie (02.10.2023)

RM06

Fall prophylaxis

klinikbezogene Umsetzung des Expertenstandards Sturzprophylaxe (02.10.2023)

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 (02.10.2023)

RM08

Regulated handling of custodial measures

Erstellung VA freiheitsentziehende Maßnahmen (02.10.2023)

RM09

Regulated handling of occurring malfunctions of devices

Ausfallkonzepte (02.10.2023)

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

Jahres CIRS-Auswertung (02.10.2023)

RM15

Preoperative, complete presentation of necessary findings

OP-Sicherheitscheckliste (02.10.2023)

RM16

Procedure to avoid procedural and patient mix-ups

OP-Sicherheitscheckliste (02.10.2023)

RM17

Standards for recovery and postoperative care

OP-Sicherheitscheckliste (02.10.2023)

RM18

Discharge management

VA Entlassmanagement (02.10.2023)

Fault reporting systems

Conference committee

Conference frequency: andere Frequenz

Measures

Bereichs- sowie prozessorientierte Risikoanalysen Checkliste „Klinisches Risikomanagement und Patientensicherheit Crew Ressource Management / Simulationen Handlungsempfehlungen M&M-Konferenzen Fallanalysen Beschwerdemanagement Critical Incident Reporting System

No. Explanation
IF01

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

As of: 01.12.2006

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: andere Frequenz

No. Explanation
EF01

CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association, National Association of Statutory Health Insurance Doctors)

EF02

CIRS Berlin (Medical Association Berlin, German Medical Association, National Association of Statutory Health Insurance Doctors)

EF03

KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors)

EF06

CIRS NRW (North Rhine and Westphalia-Lippe Medical Chambers, North Rhine Westphalia Hospital Association, North Rhine and Westphalia-Lippe Association of Statutory Health Insurance Doctors, German Medical Association, National Association of Statutory Hea