Dealing with risks in patient care
Quality management
Patrick Berse
Qualitäts- und Risikomanagement
Hervester Straße 57
45768 Marl
Phone:
02365
-911-30249
Mail:
ed.nrkk@esreb.p
Geschäftsführung, Qualitäts- und Risikomanagement, weitere Personen bei Bedarf
Conference frequency: monatlich
Risk management
Patrick Berse
Qualitäts- und Risikomanagement
Hervester Straße 57
45768 Marl
Phone:
02365
-911-30249
Mail:
ed.nrkk@esreb.p
Geschäftsführung, Kaufmännische Betriebsleitung/Beauftragter der obersten Leitung für das Risikomanagement, Pflegedirektion, Ärztliche Direktion, Qualitäts- und Risikomanager, weitere Mitarbeiter nach Bedarf
Conference frequency: halbjährlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Betriebsstättenübergreifendes QM-Handbuch mit Regelungen der risikorelevanten Themen sowie eines betriebsstättenübergreifenden RM-Konzepts: KKRN Risikostrategie, KKRN Geschäftsordnung der Organisationsstrukturen im Risikomanagement (21.07.2020) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management VA-01089 GHW Internes Notfallmanagement (18.09.2018) |
| RM05 |
Pain management KO-00817 Schmerzkonzept (14.10.2021) |
| RM06 |
Fall prophylaxis 31270 KKRN Sturzprophylaxe (19.05.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) 31274 KKRN Dekubitusprophylaxe und Dekubitusmanagement (23.04.2022) |
| RM08 |
Regulated handling of custodial measures 32113 KKRN Freiheitsentziehende Maßnahmen (FEM) (20.12.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices 22470 KKRN Ungeplante Vorkommnisse bei Medizingeräten (18.06.2021) |
| 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 40807 EKD OP-Statut (27.03.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings 40807 EKD OP-Statut (27.03.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups 40807 EKD OP-Statut (27.03.2022) |
| RM17 |
Standards for recovery and postoperative care 40807 EKD OP-Statut (27.03.2022) |
| RM18 |
Discharge management QM-Handbuch, Ordner "KKRN Entlassmanagement" mit diversen Regelungen. (13.02.2022) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Umstellung der Wasserversorgung, von Glasflaschen auf Plastikflaschen, auf den geriatrischen Stationen, um Verletzungen zu vermeiden.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 21.08.2019 |
| IF02 |
Internal evaluation of the received reports taken monatlich |
| 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: monatlich
| No. | Explanation |
|---|---|
| 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) |