Dealing with risks in patient care

Quality management

Dr. Annika Tovote

Qualitäts- und Leitbildbeauftragte

Von-Ketteler-Str. 39
48231 Warendorf

Phone: 02504 -60-193
Mail: ed.etglet-hrs@etovot.akinna

Projektsteuerungsgruppe unter Beteiligung des Direktoriums, der Mitarbeitervertretung und des Qualitätsmanagements

Conference frequency: quartalsweise

Risk management

Matthias Rothermundt

Ärztlicher Direktor

Von-Ketteler-Str. 39
48231 Warendorf

Phone: 02504 -60-122
Fax: 02504-60-121
Mail: ed.etglet-hrs@tdnumrehtor.saihttam

Projektsteuerungsgruppe unter Beteiligung des Direktoriums, der Mitarbeitervertretung und des Qualitätsmanagements

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

ÄPR/SR (01.02.2022)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

ÄPR/SR (01.02.2022)

RM05

Pain management

ÄPR Kapitel 4.11 Behandlungspfad Schmerz (01.01.2022)

RM06

Fall prophylaxis

SR Kapitel 7.8.2 (01.06.2017)

RM07

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

SR Kapitel 7.7 (01.06.2017)

RM08

Regulated handling of custodial measures

ÄPR/SR (01.02.2022)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Teambesprechungen
RM12

Use of standardised information sheets

RM16

Procedure to avoid procedural and patient mix-ups

ÄPR/SR (01.10.2021)

RM18

Discharge management

ÄPR Kapitel 4.1 (01.10.2017)

Fault reporting systems

Conference committee

Conference frequency: quartalsweise

Measures

u.a. Maßnahmen zur Verbesserung der Dekubitus- und Sturzprophylaxe

No. Explanation
IF01

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

As of: 01.03.2022

IF02

Internal evaluation of the received reports

taken jährlich

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