Dealing with risks in patient care
Quality management
Jürgen Ribbert-Elias
Qualitätsmanagement
Robert-Koch-Straße 55
59227 Ahlen
Phone:
02382
-858-693
Mail:
ed.nelha-hfs@saile-trebbir
Direktorium, Mitarbeitervertretung, Qualitätsmanagement, Medizincontrolling bei Bedarf
Conference frequency: quartalsweise
Risk management
Jürgen Ribbert-Elias
Qualitätsmanagement
Robert-Koch-Straße 55
59227 Ahlen
Phone:
02382
-858-693
Fax: 02382-858-119
Mail:
ed.nelha-hfs@saile-trebbir
Direktorium, Mitarbeitervertretung, Qualitätsmanagement, Medizincontrolling bei Bedarf
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Rahmenkonzept, Risikomatrix (03.01.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Umfangreiche Regelungen zum Notfallmanagement in der ZNA und in den Fachabteilungen des Hauses einschließlich Risikoprofilierungen der Fachzentren z.B. ZNA-Rahmenstatut (21.11.2023) |
| RM05 |
Pain management Verfahrensanweisung, Beispiel Anästhesie (25.01.2024) |
| RM06 |
Fall prophylaxis Rahmenkonzept, Risikomatrix (24.04.2024) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Rahmenkonzept, Risikomatrix (28.05.2024) |
| RM08 |
Regulated handling of custodial measures Verfahrensanweisung (18.09.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices Verfahrensanweisung und Checklisten (19.02.2024) |
| RM10 |
Structured implementation of interdisciplinary case discussions/conferences Case review conference
|
| 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 OP-Konzept, OP-Sicherheitscheckliste (07.05.2024) |
| RM15 |
Preoperative, complete presentation of necessary findings Standards und Handbücher der operierenden Abteilungen (unterschiedliche Revisionsdaten, Datumsangabe am Beispiel Alterstraumazentrum), jährliche Überprüfung (12.09.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups OP-Konzept, OP-Sicherheitscheckliste (27.06.2022) |
| RM17 |
Standards for recovery and postoperative care Standards und Handbücher der operierenden Abteilungen (unterschiedliche Revisionsdaten, Datumsangabe am Beispiel Verfahrensanweisung perioperative Planung) (12.09.2023) |
| RM18 |
Discharge management Umsetzung Rahmenvertrag Entlassmanagement, hausweites Überleitungsverfahren (Datumsangabe am Beispiel VA Entlassmanagement) (31.01.2024) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
diverse neue Verfahrensanweisungen, Schulungen
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 02.02.2023 |
| 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 bei Bedarf |
Conference committee
Conference frequency: quartalsweise
| No. | Explanation |
|---|---|
| EF06 |
CIRS NRW (North Rhine and Westphalia-Lippe Medical Associations, North Rhine-Westphalia Hospital Association, North Rhine and Westphalia-Lippe Associations of Statutory Health Insurance Physicians, German Medical Association) |