Dealing with risks in patient care

Quality management

Sarah Lückenbach

Abteilungsleitung Organisation und Qualitätsmanagement

Am Hähnchen 36
53937 Schleiden

Phone: 02443 -17-1044
Mail: ed.mhkk@hcabnekceul.haras

Geschäftsführung, Kaufmännischer Direktor, Ärztliche Direktion, Pflegedirektion, Abteilungsleitung Organisation und Qualitätsmanagement, Abteilungsleitung Pflege

Conference frequency: quartalsweise

Risk management

Sarah Lückenbach

Abteilungsleitung Organisation und Qualitätsmanagement


53932 Schleiden

Phone: 02443 -17-1044
Fax: 02443-17-1005
Mail: ed.mhkk@hcabnekceul.haras

Geschäftsführung, Kaufmännischer Direktor, Ärztliche Direktion, Pflegedirektion, Abteilungsleitung Organisation und Qualitätsmanagement, Abteilungsleitung Pflege

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

QM-Handbuch/ Nexus Curator (15.05.2020)

RM02

Regular further education and training measures

RM04

Clinical emergency management

Reanimation - Notfallalramierung (19.03.2020)

RM05

Pain management

QM-Handbuch/ Nexus Curator (15.05.2020)

RM06

Fall prophylaxis

QM-Handbuch/ Nexus Curator (15.05.2020)

RM07

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

QM-Handbuch/ Nexus Curator (15.05.2020)

RM08

Regulated handling of custodial measures

QM-Handbuch / Nexus Curator (15.05.2020)

RM09

Regulated handling of occurring malfunctions of devices

QM-Handbuch / Nexus Curator (15.05.2020)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Qualitätszirkel
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

QM-Handbuch / Nexus Curator (15.05.2020)

RM15

Preoperative, complete presentation of necessary findings

QM-Handbuch / Nexus Curator (15.05.2020)

RM16

Procedure to avoid procedural and patient mix-ups

QM-Handbuch / Nexus Curator (21.05.2019)

RM17

Standards for recovery and postoperative care

QM-Handbuch / Nexus Curator (15.05.2020)

RM18

Discharge management

QM-Handbuch / Nexus Curator (21.05.2020)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

Eine Fehlermeldung im CIRS-Meldewesen ist möglich. Die Meldung wird anonymisiert in einer Arbeitsgruppe bearbeitet und ggfs. Maßnahmen abgeleitet. Eine Rückmeldungen über Maßnahmen aus dem CIRS-Meldewesen kann erfolgen, wenn Kontaktdaten angegeben wurden.

No. Explanation
IF01

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

As of: 10.12.2018

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
EF01

CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association, National Association of Statutory Health Insurance Doctors)

EF03

KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors)

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