Dealing with risks in patient care
Quality management
Frau Sabrina Thumser
Qualitätsmanagement
Wilhelm-Busch Str. 9
53844 Troisdorf - Sieglar
Phone:
02241
-488-523
Mail:
ed.frodsiort-nekinilk-ofg@resmuht.anirbas
erweiterte Krankenhausbetriebsleitung und Qualitätsmanagement
Conference frequency: quartalsweise
Risk management
Sabrina Thumser
Qualitätsmanagement
Phone:
02241
-488-523
Mail:
ed.frodsiort-nekinilk-ofg@resmuht.anirbas
erweiterte Krankenhausbetriebsleitung und Qualitätsmanagement
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Organisationshandbuch (01.02.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Organisationshandbuch (14.06.2023) |
| RM05 |
Pain management Organisationshandbuch (14.06.2023) |
| RM06 |
Fall prophylaxis Organisationshandbuch (14.08.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Erfassung über KIS; bei Bedarf Lagerung durch Pflege im Standard-Ablauf (22.08.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Sofortige Einbindung der Medizintechnik über Störmeldung im Intranet (22.08.2023) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| RM12 |
Use of standardised information sheets |
| RM13 |
Application of standardised surgical check lists |
| RM15 |
Preoperative, complete presentation of necessary findings Wird über OP-Sicherheitscheckliste gewährleistet Team-Time-Out als weiteres Instrument zur Patientensicherheit (22.08.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Wird über OP-Sicherheitscheckliste gewährleistet Team-Time-Out als weiteres Instrument zur Patientensicherheit (22.08.2023) |
| RM17 |
Standards for recovery and postoperative care Organisationshandbuch (22.02.2022) |
| RM18 |
Discharge management Organisationshandbuch (22.03.2022) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Es konnten diverse Maßnahmen eingeleitet werden, die sich auf Änderungen organisatorischer Abläufe beziehen.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 03.06.2019 |
| 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 bei Bedarf |
Conference committee
Conference frequency: monatlich
| 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 |