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

Statut des Qualitätsmanagementsystems, Konzept Risikomanagementsystem, Statut und VA Fehlermeldesystem, Veröffentlichung CIRS, Kurzanleitung Organisationshandbuch, VA Befragung, VA interne Audits und Begehungen (21.01.2023)

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

Statut des Qualitätsmanagementsystems, Konzept Risikomanagementsystem, Statut und VA Fehlermeldesystem, Veröffentlichung CIRS, Kurzanleitung Organisationshandbuch, VA Befragung, VA interne Audits und Begehungen (21.01.2023)

RM07

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

VA Dekubitusprophylaxe (07.06.2021)

RM08

Regulated handling of custodial measures

VA Fixierung eines Patienten (16.02.2022)

RM09

Regulated handling of occurring malfunctions of devices

Verfahrensanweisungen Medizinprodukte (18.04.2024)

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 und Patientensicherheit (19.06.2024)

RM15

Preoperative, complete presentation of necessary findings

Checkliste OP-Vorbereitung und Patientensicherheit (19.06.2024)

RM16

Procedure to avoid procedural and patient mix-ups

VA Patientenidentifikationsarmband (15.05.2024)

RM17

Standards for recovery and postoperative care

Standard für die postoperative Überwachung (10.09.2024)

RM18

Discharge management

VA Entlassung und externe Verlegung (10.06.2024)

Fault reporting systems

Conference committee

Conference frequency: quartalsweise

Measures

VA Fehlermeldesystem CIRS / EMO, VA Meldung von Mitarbeitern, FO CIRS Meldung

No. Explanation
IF01

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

As of: 01.02.2023

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 quartalsweise

Conference committee

Conference frequency: halbjährlich

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)