Dealing with risks in patient care

Quality management

Dr. med. Irena Kriegesmann-Rembs

Leitung Klinikorganisation und Qualitätsmanagement

Werler Straße 110
59063 Hamm

Phone: 02381 -589-1751
Mail: ed.nekinilk-oelav@mmah.mq

Das Qualitäts- und Risikomanagement wird von der Krankenhausleitung gesteuert.

Conference frequency: monatlich

Risk management

Irena Kriegesmann-Rembs

Leitung Klinikorganisation und Qualitätsmanagement

Phone: 02381 -589-1751
Fax: 02381-589-1177
Mail: ed.nekinilk-oelav@mmah.mq

Das Qualitäts- und Risikomanagement wird von der Krankenhausleitung gesteuert.

Conference frequency: monatlich

Risk management instruments and measures

No. Explanation
RM01

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

QM-Handbuch (10.08.2022)

RM02

Regular further education and training measures

RM04

Clinical emergency management

QM-Handbuch (10.08.2022)

RM05

Pain management

QM-Handbuch (10.08.2022)

RM06

Fall prophylaxis

QM-Handbuch (10.08.2022)

RM07

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

QM-Handbuch (10.08.2022)

RM08

Regulated handling of custodial measures

QM-Handbuch (10.08.2022)

RM09

Regulated handling of occurring malfunctions of devices

QM-Handbuch (10.08.2022)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Palliativbesprechungen
  • Qualitätszirkel
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

QM-Handbuch (10.08.2022)

RM15

Preoperative, complete presentation of necessary findings

QM-Handbuch (10.08.2022)

RM16

Procedure to avoid procedural and patient mix-ups

QM-Handbuch (10.08.2022)

RM17

Standards for recovery and postoperative care

QM-Handbuch (10.08.2022)

RM18

Discharge management

QM-Handbuch (10.08.2022)

Fault reporting systems

Conference committee

Conference frequency: bei Bedarf

Measures

NRFit: Umsetzung von Farbcodierung und Konnektoren für Infusionssysteme (intravenös, enteral und peripher)

No. Explanation
IF01

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

As of: 31.08.2022

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: 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