Dealing with risks in patient care
Quality management
Thomas Schulz
Qualitätsmanagementbeauftragter
Zollernstr. 40
44379 Dortmund
Phone:
02305
-294-5321
Mail:
ed.tfahcslleseg-sakul@zluhcs.t
Standortkonferenz (Chefärzte, Standortleitung, Pflegedirektion, Qualitätsmanagement, Abteilungsleitungen)
Conference frequency: quartalsweise
Risk management
Thomas Schulz
Qualitätsmanagementbeauftragter
Zollernstr. 40
44379 Dortmund
Phone:
02305
-294-5321
Fax: 0231-6798-3059
Mail:
ed.tfahcslleseg-sakul@zluhcs.t
Standortkonferenz (Chefärzte, Standortleitung, Pflegedirektion, Qualitätsmanagement, Abteilungsleitungen)
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitätsmanagementhandbuch (01.10.2020) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Vorgehen beim medizinischen Notfall/Notfallkoffer (23.06.2021) |
| RM05 |
Pain management Qualifizierte Schmerztherapie (Schmerzkonzept) MultimodaleSchmerztherapie (01.05.2016) |
| RM06 |
Fall prophylaxis Standard Sturzprophylaxe (05.10.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Standard Dekubitusprophylaxe (05.10.2021) |
| RM08 |
Regulated handling of custodial measures Standard Fixierung (11.03.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices Meldung von Vorkommnissen bei der Anwendung von Medizinprodukten (14.08.2020) |
| 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 OP-Sicherheitscheckliste mit Team time out (08.06.2011) |
| RM15 |
Preoperative, complete presentation of necessary findings OP-Sicherheitscheckliste mit Team time out (08.06.2011) |
| RM16 |
Procedure to avoid procedural and patient mix-ups OP-Sicherheitscheckliste mit Team time out (08.06.2011) |
| RM17 |
Standards for recovery and postoperative care Standard Postoperative Versorgung (17.01.2022) |
| RM18 |
Discharge management Standard Entlassungsmanagement (05.10.2021) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Leitlinie zum Umgang mit opioidhaltigen Pflastern, Maßnahmen gegen Verwechslung von Medikamenten Schulungsmaßnahmen Sterilgutversorgung Hinweis auf dem Blister bei Medikamenten, die zusätzlich Ampullen das Lösungsmittel enthalten
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 01.12.2016 |
| IF02 |
Internal evaluation of the received reports taken jährlich |
| 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 |
|---|---|
| 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 |