Dealing with risks in patient care

Quality management

Frau Marion Noga

Medizincontrolling; QMB im Gesundheitswesen

Dr.-Moeller-Straße 15
58332 Schwelm

Phone: 02336 -48-1509
Mail: ed.tiehdnuseg-soileh@agon.noiram

Betriebsleitung; optional QMB und weitere Teilnehmer

Conference frequency: wöchentlich

Risk management

Babette Pinner

Sekretariat Klinikgeschäftsführung

Phone: 02336 -481422-
Mail: ed.tiehdnuseg-soileh@rennip.ettebab

Betriebsleitung; optional QMB und weitere Teilnehmer

Conference frequency: wöchentlich

Risk management instruments and measures

No. Explanation
RM02

Regular further education and training measures

RM03

Employee surveys

RM05

Pain management

Handlungsempfehlung Schmerzmanagement in der Pflege bei akuten und chronischen Schmerzen (01.09.2019)

RM06

Fall prophylaxis

Beschluss der FG Pflege Sturzprophylaxe (01.02.2023)

RM07

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

Beschluss der FG Pflege Dekubitusprophylaxe (01.11.2021)

RM09

Regulated handling of occurring malfunctions of devices

Verfahrensstandard Umgang mit Produktproblemen (ZD Einkauf) (29.05.2015)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Mortalitäts- und Morbiditätskonferenzen
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

Konzernregelung OP-Sicherheit (27.01.2022)

RM15

Preoperative, complete presentation of necessary findings

Konzernregelung OP-Sicherheit (27.01.2022)

RM16

Procedure to avoid procedural and patient mix-ups

Konzernregelung OP-Sicherheit (27.01.2022)

Fault reporting systems

Conference committee

Conference frequency: bei Bedarf

Measures

Aus den gemeldeten/ registrierten Ereignissen erfolgt jeweils eine individuelle Anpassung des betroffenen Prozesses auf der Basis von PDCA.

No. Explanation
IF01

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

As of: 21.02.2018

IF02

Internal evaluation of the received reports

taken bei Bedarf

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: bei Bedarf

No. Explanation
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