Dealing with risks in patient care

Quality management

Daniela Spiekermann

Qualitäts- und Risikomanagement

Annostraße 1
57392 Schmallenberg-Grafschaft

Phone: 02972 -791-3058
Mail: ed.gkkf@nnamrekeips.d

Geschäftsführer, Ärztlicher Direktor, Pflegedirektorin, Qualitätsmanagement

Conference frequency: bei Bedarf

Risk management

Daniela Spiekermann

Qualitäts- und Risikomanagement

Phone: 02972 -791-3058
Fax: 02972-791-1263
Mail: ed.gkkf@nnamrekeips.d

Geschäftsführer, Ärztlicher Direktor, Pflegedirektorin, Qualitätsmanagement

Conference frequency: bei Bedarf

Risk management instruments and measures

No. Explanation
RM01

Comprehensive quality and/or risk management documentation (QM/RM documentation) is available

DIN ISO EN 9001:2015 (27.10.2023)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

DIN ISO EN 9001:2015 (27.10.2023)

RM06

Fall prophylaxis

DIN ISO EN 9001:2015 (27.10.2023)

RM07

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

DIN ISO EN 9001:2015 (27.10.2023)

RM08

Regulated handling of custodial measures

DIN ISO EN 9001:2015 (27.10.2023)

RM09

Regulated handling of occurring malfunctions of devices

DIN ISO EN 9001:2015 (27.10.2023)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Palliativbesprechungen
  • Qualitätszirkel
RM12

Use of standardised information sheets

RM16

Procedure to avoid procedural and patient mix-ups

DIN ISO EN 9001:2015 (27.10.2023)

RM18

Discharge management

DIN ISO EN 9001:2015 (27.10.2023)

Fault reporting systems

Conference committee

Conference frequency: bei Bedarf

Measures

Umsetzung der Expertenstandards, CIRS

No. Explanation
IF01

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

As of: 27.10.2023

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 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