Dealing with risks in patient care
Quality management
Dr. Siegfried Borker
Qualitätsmanagement-Koordinator
Hasestraße 16
49565 Bramsche
Phone:
05461
-805-1111
Mail:
ed.nekinilk-nesnets-slein@rekrob.deirfgeis
Mitglieder der Krankenhausleitung
Conference frequency: monatlich
Risk management
Siegfried Borker
Qualitätsmanagement-Koordinator
Hasestraße 16
49565 Bramsche
Phone:
05461
-805-1111
Fax: 05461-805-1109
Mail:
ed.nekinilk-nesnets-slein@rekrob.deirfgeis
Verwaltungsdirektor, Pflegedirektorin, Qualitätsmanagement-Koordinator und bei Bedarf weitere Abteilungen/ Funktionsbereiche.
Conference frequency: halbjährlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikomanagement-Handbuch Niels-Stensen-Kliniken, Dokumenten-Nr. 016369 (15.08.2022) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Verfahrensanweisung Notfallmanagement NKB, Dokumenten-Nr.: 000211 (22.07.2022) |
| RM05 |
Pain management Leitlinie Akutschmerztherapie NSK, Dokumenten-Nr.: 004684 (24.08.2021) |
| RM06 |
Fall prophylaxis Pflegestandard Sturzprophylaxe, Dokumenten-Nr.: 007846 (04.07.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Pflegestandard Dekubitusprophylaxe, Dokumenten-Nr.: 006270 (04.07.2023) |
| RM08 |
Regulated handling of custodial measures Freiheitsentziehende Maßnahmen, Dokumenten-Nr.: 014967 (12.04.2019) |
| RM09 |
Regulated handling of occurring malfunctions of devices Verfahrensanweisung Meldung von Vorkommnissen mit Medizinprodukten, Dokumenten-Nr.: 013311 (12.12.2022) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM16 |
Procedure to avoid procedural and patient mix-ups Risikomanagement-Handbuch Niels-Stensen-Kliniken, Dokumenten-Nr. 016369 (15.08.2022) |
| RM18 |
Discharge management Verfahrensanweisung Entlassmanagement NKB, Dokument Nr.: 014449 (09.03.2020) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Beispiel-Meldungen: Nr. 1619: Antibiotika (Beinahe-Verwechselung) / Nr. 1661 Heizkörper (Verbrennungsgefahr) / Nr. 1848: Notfall (fehlerhafte Alarmierung)
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 02.03.2022 |
| 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: bei Bedarf
| No. | Explanation |
|---|---|
| EF03 |
KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors) |