Dealing with risks in patient care

Quality management

Svenja Görtz

Leitung Qualitäts- und Risikomanagement

Basilikastraße 55
47623 Kevelaer

Phone: 02821 -490-1265
Mail: ed.elkk@ztreog.ajnevs

Die übergeordnete Qualitäts-und Risikodokumentation ist in der Unternehmenspolitik sowie der Risikopolitik beschrieben. Miglieder: Betriebsleitung, Qualitäts-und Risikobeauftragte der Fachabteilungen

Conference frequency: quartalsweise

Risk management

Svenja Görtz

Leitung Qualitäts- und Risikomanagement

Phone: 02821 -490-1265
Fax: 02821-490-1257
Mail: ed.elkk@ztreog.ajnevs

Die übergeordnete Qualitäts-und Risikodokumentation ist in der Unternehmenspolitik sowie der Risikopolitik beschrieben. Miglieder: Betriebsleitung, Qualitäts-und Risikobeauftragte der Fachabteilungen

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

RM01 (16.07.2022)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Notfallmanagement (16.07.2022)

RM05

Pain management

Schmerzmanagement (16.07.2022)

RM06

Fall prophylaxis

Expertenstandard Sturz (16.07.2022)

RM07

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

Expertenstandard Dekubitusprophylaxe (16.07.2022)

RM08

Regulated handling of custodial measures

Umgnag mit freiheitsentziehenden Maßnahmen (16.07.2022)

RM09

Regulated handling of occurring malfunctions of devices

Medizinproduktemanagement (16.07.2022)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • 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

OP-Statut, Verfahrensanweisungen, Checklisten (16.07.2022)

RM15

Preoperative, complete presentation of necessary findings

RM01 (16.07.2022)

RM16

Procedure to avoid procedural and patient mix-ups

Prä- und Intraoperative Checklisten, Patientenidentifikationsarmbänder, Team-Time-Out (16.07.2022)

RM17

Standards for recovery and postoperative care

Verfahrensanweisungen Aufwachraum, Überwachungs-Verlegungsdokumentation (16.07.2022)

RM18

Discharge management

Entlassmanagement nach dem Expertenstandard Entlassung, sowie Umsetzung § 39 Absatz 1a SGB V (16.07.2022)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Patientenidentifikationsarmbänder Präoperative Checklisten Intraoperative Checklisten Team Time Out Checklisten bei Übergabe von Patienten in den OP-Bereich Sturzprävention Arzneimitteltherapiesicherheit elektronisch, AiDKlinik® Risikomatrix, Risikobewertung Aufklärung in verschiedenen Sprachen Medizinproduktemanagement Antibiotic Stewardship-Team

No. Explanation
IF01

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

As of: 16.07.2022

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 quartalsweise

Conference committee

Conference frequency: quartalsweise

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)

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

EF08

CIRS Emergency Medicine (Department of Anaesthesia, Intensive Care Medicine and Emergency Medicine, Kempten Hospital)

EF10

CIRS of the German Society of Surgery (DGCH)