Dealing with risks in patient care
Quality management
Uwe Petersen
Regionalleitung Qualitätsmanagement Nordrhein-Westfalen / Qualitäts-/klin. Risikomanagement Sana-Klinikum Remscheid
Burger Straße 211
42859 Remscheid
Phone:
02191
-13-3013
Mail:
ed.anas@nesretep.ewu
Geschäftsführung, Klinikmanager, Ärztliche Direktion, Pflegedirektion
Conference frequency: monatlich
Risk management
Uwe Petersen
Regionalleitung Qualitätsmanagement Nordrhein-Westfalen / Qualitäts-/klin. Risikomanagement Sana-Klinikum Remscheid
Phone:
02191
-13-3013
Fax: 02191-13-3029
Mail:
ed.anas@nesretep.ewu
Geschäftsführerin, Klinikmanager, Ärztlicher Direktor, Pflegedirektorin, Regionalleiter NRW Qualitätsmanagement/Risikomanagement
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available DOK Klinisches Fehler- und Risikomanagement-Nichtkonformitäten (12.11.2020) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management VA Umgang Notfallkoffer, VA ANÄ Notfallteam (26.08.2024) |
| RM05 |
Pain management Konzept perioperative Schmerztherapie (21.04.2020) |
| RM06 |
Fall prophylaxis VA Sturzmanagement (26.07.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) VA Dekubitusprophylaxe (27.09.2021) |
| RM08 |
Regulated handling of custodial measures VA Fixierung; VA Kriseninterventionsbereich ZSG (24.05.2024) |
| RM09 |
Regulated handling of occurring malfunctions of devices Samba-Handbuch (30.08.2021) |
| 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 VA OP-Organisation im Regelbetrieb (30.08.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings VA OP-Organisation im Regelbetrieb (30.08.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups OP-Sicherheitscheckliste, VA Patientenidentifikationsband (30.08.2021) |
| RM17 |
Standards for recovery and postoperative care VA Aufwachraum; VA Warteraum-Ruheraum-Diagnostikzentrum (21.05.2024) |
| RM18 |
Discharge management VA Entlassmanagement (30.08.2021) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Hygienebegehungen, Apothekenbegehungen, unvermutete Begehungen verschiedener Behörden, interne und externe Audits im Rahmen der ISO 9001- und Zentrumszertifizierungen, Dokumentationsaudits, externe und interne Risikoaudits nach Risikopräventionskatalog, Peer Reviews, Fallanalysen nach London Protokoll, Qualitätsgespräche, Anpassungen im Kontext Arzneimitteltherapiesicherheit, Auseinandersetzung mit den Erkenntnissen aus Quick Alerts und übergeordneten CIRS-Meldungen u. a.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 21.03.2024 |
| 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 quartalsweise |
Conference committee
Conference frequency: quartalsweise
| No. | Explanation |
|---|---|
|
Other |