Dealing with risks in patient care
Quality management
Frau Kristin Wilkes
Leitung Qualitäts- und Risikomanagement
Am Finkenhügel 1
49076 Osnabrück
Phone:
0541
-405-5112
Mail:
ed.so-mukinilk@sekliW.nitsirK
Conference frequency:
Risk management
Kristin Wilkes
Leitung Qualitäts- und Risikomanagement
49028 Osnabrück
Phone:
0541
-405-5112
Fax: 0541-405-1099
Mail:
ed.so-mukinilk@sekliW.nitsirK
Risikomanagement Kernteam: Ärztliche Direktion, Pflegedirektion, Ltg Personal und Recht Ltg Betriebswirtschaft und Finanzen Ltg Services und Technologien Ltg Unternehmensentwicklung Krankenhaushygiene Betriebsrat Interne Revision Compliance Med. Infrastruktur
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Organisationshandbuch (23.09.2024) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Organisationshandbuch (23.09.2024) |
| RM05 |
Pain management Organisationshandbuch (23.09.2024) |
| RM06 |
Fall prophylaxis Organisationshandbuch (23.09.2024) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Organisationshandbuch (23.09.2024) |
| RM08 |
Regulated handling of custodial measures Organisationshandbuch (23.09.2024) |
| RM09 |
Regulated handling of occurring malfunctions of devices Organisationshandbuch (23.09.2024) |
| 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 Organisationshandbuch (23.09.2024) |
| RM15 |
Preoperative, complete presentation of necessary findings Organisationshandbuch (23.09.2024) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Organisationshandbuch (23.09.2024) |
| RM17 |
Standards for recovery and postoperative care Organisationshandbuch (23.09.2024) |
| RM18 |
Discharge management Organisationshandbuch (23.09.2024) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Ziel ist die Erhöhung der Patientensicherheit. Durch Ziel ist die Erhöhung der Patientensicherheit. Durch eine frühzeitige Identifikation von möglichen Fehlerquellen und Einleitung von Maßnahmen sollen Schäden oder potentiellen Behandlungsfehler vermieden werden. Behandlungsfehler vermieden werden.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 06.04.2023 |
| 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 |
|---|---|
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |