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Luisenhospital Aachen

Dealing with risks in patient care

Quality management

Responsible person

Dipl. Pflegewirt Uwe Osterland

Qualitäts- und Risikomanagement

Boxgraben 99
52064 Aachen

Phone: 0241 -414-2470
Mail: ed.latipsohnesiul@bmq

Steering committee

Das Gremium besteht aus Vorstandsvorsitzendem, dem Verwaltungsdirektor und Qualitäts- und Risikomanagementbeauftragten. Mindestens 1x jährlich findet für die einzelnen Abteilungsleiter eine Managementbewertung statt.

Conference frequency: monatlich

Risk management

Responsible person

Uwe Osterland

Qualitäts- und Risikomanagement

Phone: 0241 -414-2470
Fax: 0241-414-2260
Mail: ed.latipsohnesiul@bmq

Steering committee

Conference frequency: monatlich

Risk management instruments and measures

Instruments and measures

No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikomanagementsystem in den Einrichtungen des EVK (29.07.2022)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Risikomanagementsystem in den Einrichtungen des EVK (29.07.2022)
RM05	Pain management Risikomanagementsystem in den Einrichtungen des EVK (29.07.2022)
RM06	Fall prophylaxis Risikomanagementsystem in den Einrichtungen des EVK (29.07.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Risikomanagementsystem in den Einrichtungen des EVK (29.07.2022)
RM08	Regulated handling of custodial measures Risikomanagementsystem in den Einrichtungen des EVK (29.07.2022)
RM09	Regulated handling of occurring malfunctions of devices Risikomanagementsystem in den Einrichtungen des EVK (29.07.2022)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Pathologiebesprechungen Palliativbesprechungen 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 Risikomanagementsystem in den Einrichtungen des EVK (29.07.2022)
RM15	Preoperative, complete presentation of necessary findings Risikomanagementsystem in den Einrichtungen des EVK (29.07.2022)
RM16	Procedure to avoid procedural and patient mix-ups Risikomanagementsystem in den Einrichtungen des EVK (29.07.2022)
RM17	Standards for recovery and postoperative care Risikomanagementsystem in den Einrichtungen des EVK (29.07.2022)
RM18	Discharge management Risikomanagementsystem in den Einrichtungen des EVK (29.07.2022)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Einsatz von Onkologischen Pflegefachkräften Einsatz von Risikoadjustierten Qualitätszirkeln Beauftragtenbesprechung

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 17.10.2016
IF02	Internal evaluation of the received reports taken jährlich
IF03	Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken jährlich

No.

Explanation

IF01

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

As of: 17.10.2016

IF02

Internal evaluation of the received reports

taken jährlich

IF03

Training of employees in handling the error reporting system and in implementing the findings from the error reporting system

taken jährlich

Across all institutions

Conference committee

Conference frequency: monatlich

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)