Dealing with risks in patient care

Quality management

Frank Schneider

Qualitäts- und Risikomanagement

Preußenstraße 84
41464 Neuss

Phone: 02131 -888-7015
Mail: ed.mukinilkdnalniehr@redienhcs.knarf

Qualitäts- und Risikomanagement, Pflegedienstleitung, Abt.Betrieb, Justiziariat, IT, Klinikmanager

Conference frequency: monatlich

Risk management

Frank Schneider

Qualitäts- und Risikomanagement

Phone: 02131 -888-7015
Fax: 02131-888-7099
Mail: ed.mukinilkdnalniehr@redienhcs.knarf

Qualitäts- und Risikomanagement, Pflegedienstleitung, Abt.Betrieb, Justiziariat, IT, Klinikmanager

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

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

Name der Verfahrensbeschreibung/SOP: Verfahrensanweisung Dokumentenlenkung (15.01.2020)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Handlungsanweisung Klinisches Notfallmanagement (12.01.2021)

RM05

Pain management

Standard Schmerztherapie (20.02.2021)

RM06

Fall prophylaxis

Handlungsempfehlung Sturzprophylaxe (01.08.2019)

RM07

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

VA Dekubitusprophylaxe (01.07.2015)

RM08

Regulated handling of custodial measures

Handlungsanweisung Freiheitsentziehende Maßnahmen (01.12.2018)

RM09

Regulated handling of occurring malfunctions of devices

Verfahrensanweisungen Medizinprodukte (29.10.2019)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Qualitätszirkel
  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Pathologiebesprechungen
  • Palliativbesprechungen
  • Röntgenbesprechung
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

Checkliste OP-Vorbereitung (03.06.2019)

RM15

Preoperative, complete presentation of necessary findings

Checkliste OP-Vorbereitung (14.11.2020)

RM16

Procedure to avoid procedural and patient mix-ups

Checkliste OP-Patientensicherheit (03.06.2019)

RM17

Standards for recovery and postoperative care

Standard Verlegung aus dem Aufwachraum, Standard für die postoperative Überwachung (17.07.2019)

RM18

Discharge management

VA Entlassungsmanagement (01.09.2017)

Fault reporting systems

Conference committee

Conference frequency: monatlich

Measures

- Anpassung der WHO-Checkliste Patientensicherheit- - Erarbeitung von klinikübergreifenden Arbeitsanweisungen

No. Explanation
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 quartalsweise

Conference committee

Conference frequency: quartalsweise

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