Dealing with risks in patient care
Quality management
Karen Schäfer
Leitung Qualitäts-und Risikomanagement
Klosterstraße 2
50126 Bergheim
Phone:
02271
-87-162
Mail:
ed.nennitillec@refeahcs.nerak
Geschäftsführung, Kaufmännische Leitung, Ärztliche Direktion, Pflegedirektion, Chefärzte, Qualitäts- und Risikomanagment.
Conference frequency: andere Frequenz
Risk management
Karen Schäfer
Leitung Qualitäts-und Risikomanagement
Phone:
02271
-87-162
Fax: 02271-87-126
Mail:
ed.nennitillec@refeahcs.nerak
Oberarzt Chirurgie, Hygienefachkraft, OP-Leitungen, Qualitäts- und Risikomanagement.
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Wirksamkeitsverfolgung von Vorbeuge- u. Korrekturmaßnahmen (13.08.2025) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management AB-033 Medizinischer Notfall, Standards, Checklisten, Schockraumregelungen, REA-Team, Notfallausrüstung (Koffer, Wagen, Rucksack). (15.08.2025) |
| RM05 |
Pain management DO-17266 Konzept Schmerztherapie, Schmerzdokumentationen, Expertenstandards und Postoperative Schmerztherapie AWR (02.05.2023) |
| RM06 |
Fall prophylaxis Sturzprophylaxe basierend auf den nationalen Expertenstandard "Sturzprophylaxe in der Pflege" (17.09.2025) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusprophylaxe u. Behandlung basierend auf den nationalen Expertenstandard "Dekubitusprophylaxe in der Pflege" (15.09.2025) |
| RM08 |
Regulated handling of custodial measures Verfahrensanweisung Anregung von Betreuungseilmaßnahmen (16.06.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices AB-101 Überwachung und Messung (25.08.2025) |
| 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-Statut (05.06.2024) |
| RM15 |
Preoperative, complete presentation of necessary findings OP-Statut (05.06.2024) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Perioperative Sicherheitscheckliste (06.02.2024) |
| RM17 |
Standards for recovery and postoperative care AB-053 Versorgung der Patienten im Aufwachraum (23.10.2025) |
| RM18 |
Discharge management Verfahrensanweisung Zentrales Entlassmanagement (30.05.2023) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Zur Optimierung der Patientensicherheit wurde die perioperative Sicherheitscheckliste , weitere OP- und Notfallwagen Checklisten etc. verbessert.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 31.01.2025 |
| 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: bei Bedarf
| 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) |