Dealing with risks in patient care
Quality management
Dr. Siegfried Borker
Qualitätsmanagement-Koordinator
Hasestraße 16
49565 Bramsche
Phone:
05461
-805-1111
Mail:
ed.ksn@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.ksn@rekrob.deirfgeis
Verwaltungsdirektion, Pflegedirektion, 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 (29.07.2025) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Verfahrensanweisung Notfallmanagement NKB, Dokumenten-Nr.: 000211 (03.06.2025) |
| RM05 |
Pain management Leitlinie Akutschmerztherapie NSK, Dokumenten-Nr.: 004684 (30.10.2024) |
| 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 (11.09.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Verfahrensanweisung Meldung von Vorkommnissen mit Medizinprodukten, Dokumenten-Nr.: 013311 (20.01.2025) |
| 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 Verfahrensanweisung - Vermeidung einer Eingriffsverwechslung in den NSK - Nr. 026792 (28.10.2024) |
| RM18 |
Discharge management Verfahrensanweisung Entlassmanagement NKB, Dokument Nr.: 014449 (15.09.2023) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Notfallsituation Sepsis optimiert, Videolaryngoskop eingeführt,
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 29.07.2025 |
| 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 Association, German Nursing Council, German Medical Association) |