Dealing with risks in patient care
Quality management
Anne Katrin Körber
Qualitätsbeauftragte
Gerhard-Kienle-Weg 4 Gerhard-Kienle-Weg 4
58313 Herdecke
Phone:
02330
-62-2477
Mail:
ed.suahneknarkstfahcsniemeg@rebreok.a
Unternehmensleitung, Arzt für Qualitätsmanagement, Pflegedirektion
Conference frequency: monatlich
Risk management
Anne Katrin Körber
Qualitätsbeauftragte
Gerhard-Kienle-Weg 4
58313 Herdecke
Phone:
02330
-62-2477
Fax: 02330-62-4085
Mail:
ed.suahneknarkstfahcsniemeg@rebreok.a
Unternehmensleitung, Arzt für Qualitätsmanagement, Pflegedirektion
Conference frequency: monatlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Klinische Risikoanalyse (09.03.2021) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM05 |
Pain management Standard zur perioperativen Schmerztherapie (16.11.2022) |
| RM06 |
Fall prophylaxis Standard Sturzprophylaxe (08.07.2019) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Standard Dekubitus Prophylaxe (30.11.2023) |
| RM08 |
Regulated handling of custodial measures Standard Fixierung, Antrag Richterliche Betreuung (26.09.2024) |
| RM09 |
Regulated handling of occurring malfunctions of devices Verfahrensanweisung Geräteüberwachung (30.04.2024) |
| 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 Checkliste (WHO) (14.12.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings OP Checkliste (16.11.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups OP Checkliste (WHO) , Team Time Out (14.12.2023) |
| RM17 |
Standards for recovery and postoperative care Checkliste Aufwachraum (26.01.2023) |
| RM18 |
Discharge management Entlassplanung und Checkliste Entlassmanagement (20.06.2024) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Anti Gewalttraining - Notfallplan aktualisiert- Hygieneplan aktualisiert - Antibiotika Leitfaden Kitteltasche-
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 12.06.2024 |
| 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 jährlich |
Conference committee
Conference frequency: bei Bedarf
| 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) |