Dealing with risks in patient care
Quality management
Sabine Nimax
Regionale Leitung Qualitäts- und Risikomanagment
Steinfeldstraße 5
52222 Stolberg (Rheinl.)
Phone:
02402
-107-4006
Mail:
ed.mehelhteb@xamin.enibas
Regelmäßige Teilnahme des QMBs an Direktoriumssitzungen Regelmäßiges Treffen der QM-Koordinatoren (Verantwortliche aller klinischen, pflegerischen und administrativen Arbeitsbereiche)
Conference frequency: monatlich
Risk management
Sabine Nimax
Regionale Leitung Qualitäts- und Risikomanagment
Steinfeldstraße 5
52222 Stolberg (Rheinl.)
Phone:
02402
-107-4006
Fax: 02402-107-8227
Mail:
ed.mehelhteb@xamin.enibas
Regelmäßige Teilnahme des QMBs an Direktoriumssitzungen Regelmäßiges Treffen der QM-Koordinatoren (Verantwortliche aller klinischen, pflegerischen und administrativen Arbeitsbereiche)
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitätsmanagementhandbuch (03.05.2024) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management QMH (03.05.2024) |
| RM05 |
Pain management QMH (03.05.2024) |
| RM06 |
Fall prophylaxis Expertenstandard/QMH (03.05.2024) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard/QMH (03.05.2024) |
| RM08 |
Regulated handling of custodial measures QMH (03.05.2024) |
| RM09 |
Regulated handling of occurring malfunctions of devices QMH (03.05.2024) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM13 |
Application of standardised surgical check lists |
| RM14 |
Preoperative summary of predictable critical surgical steps, surgical time and expected blood loss QMH (03.05.2024) |
| RM15 |
Preoperative, complete presentation of necessary findings QMH (03.05.2024) |
| RM16 |
Procedure to avoid procedural and patient mix-ups QMH (03.05.2024) |
| RM17 |
Standards for recovery and postoperative care QMH (03.05.2024) |
| RM18 |
Discharge management QMH (03.05.2024) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Umsetzung diverser Fallbesprechungen in den klinischen Abteilungen Publikation mehrerer nationaler und internationaler CIRS-Fälle
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 24.05.2024 |
| IF02 |
Internal evaluation of the received reports taken quartalsweise |
| IF03 |
Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken jährlich |
Conference committee
Conference frequency: monatlich
| No. | Explanation |
|---|---|
|
Other |
|
| EF03 |
KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association) |