Dealing with risks in patient care

Quality management

MScN Regina Rosenberg

Qualitätsmanagement/Risikomanagement

Hospitalstrasse 6-10
58099 Hagen

Phone: 02331 -805-761
Mail: ed.negah-hkk@grebnesor.r

Geschäftsführung, Betriebsleitung (Pflegedirektorin, Ärztlicher Direktor, Klinikmanagement), Qualitätsmanagementbeauftragte

Conference frequency: monatlich

Risk management

Regina Rosenberg

Qualitätsmanagement/Risikomanagement


58018 Hagen

Phone: 02331 -805-761
Mail: ed.negah-hkk@grebnesor.r

Geschäftsführung, Betriebsleitung (Pflegedirektorin, Ärztlicher Direktor, Klinikmanagement), Qualitätsmanagementbeauftragte

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

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

SOP's, Dienstanweisungen, Rahmenvereinbarungen etc. Risikomatrix (20.05.2022)

RM02

Regular further education and training measures

RM04

Clinical emergency management

Klinisches Notfallmanagement (22.12.2021)

RM05

Pain management

Rahmenvereinbarung Perioperative Schmerztherapie für alle operativen Kliniken (21.11.2022)

RM06

Fall prophylaxis

SOP Sturzmanagement (Prävention von Stürzen, Risikoeinschätzung, Systematische Erfassung aller Stürze, Auswertung aller Sturzereignisse) (01.06.2021)

RM07

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

SOP Interne Leitlinie Dekubitus (01.06.2021)

RM08

Regulated handling of custodial measures

Leitlinie Fixierung Somatik (19.09.2022)

RM09

Regulated handling of occurring malfunctions of devices

SOP Medizintechnik (27.11.2021)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Palliativbesprechungen
RM12

Use of standardised information sheets

RM13

Application of standardised surgical check lists

RM15

Preoperative, complete presentation of necessary findings

Sicherstellung wird durch eine Checkliste unterstützt (18.06.2022)

RM16

Procedure to avoid procedural and patient mix-ups

SOP Verfahren Vermeidung von Eingriffs- und Seitenverwechselungen (18.06.2022)

RM18

Discharge management

SOP's, Dienstanweisungen, Rahmenvereinbarungen etc. Risikomatrix (20.05.2022)

Fault reporting systems

Conference committee

Conference frequency: quartalsweise

Measures

Austausch von Trennwänden; Anpassung von Pflegepersonalausstattung

No. Explanation
IF01

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

As of: 28.01.2020

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 bei Bedarf

Conference committee

Conference frequency: quartalsweise

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