Dealing with risks in patient care
Quality management
Frau Annegret Voß
Qualitäts- und Risikomanagementbeauftragte
Rochusstr. 2
40479 Düsseldorf
Phone:
0211
-4400-2199
Mail:
ed.nekinilk-dkkv@ssov.tergenna
Betriebsleitung
Conference frequency: quartalsweise
Risk management
Annegret Voß
Qualitäts- und Risikomanagementbeauftragte
Phone:
0211
-4400-2199
Fax: 0211-4400-2016
Mail:
ed.nekinilk-dkkv@ssov.tergenna
interdisziplinäres CIRS- Team
Conference frequency: bei Bedarf
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Dokumentation im Rahmen von Zertverfahren (31.12.2021) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Dokumentation im Rahmen von Zertverfahren (31.12.2021) |
| RM05 |
Pain management Dokumentation im Rahmen von Zertverfahren (31.12.2021) |
| RM06 |
Fall prophylaxis Dokumentation im Rahmen von Zertverfahren (31.12.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dokumentation im Rahmen von Zertverfahren (31.12.2021) |
| RM08 |
Regulated handling of custodial measures Dokumentation im Rahmen von Zertverfahren (31.12.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices Dokumentation im Rahmen von Zertverfahren (31.12.2021) |
| 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 Dokumentation im Rahmen von Zertverfahren (31.12.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings Dokumentation im Rahmen von Zertverfahren (31.12.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Dokumentation im Rahmen von Zertverfahren (31.12.2021) |
| RM17 |
Standards for recovery and postoperative care Dokumentation im Rahmen von Zertverfahren (31.12.2021) |
| RM18 |
Discharge management Dokumentation im Rahmen von Zertverfahren (31.12.2021) |
Fault reporting systems
Conference committee
Conference frequency: bei Bedarf
Measures
Im Rahmen von Qualitätszirkeln / CIRS-Team-Treffen und M&M-Konferenzen werden Fehlermeldungen bewertet und ggf. Maßnahmen zur Korrektur oder Verbesserungen eingeleitet.
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 23.02.2023 |
| 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 |
|---|---|
| EF02 |
CIRS Berlin (Berlin Medical Association, German Medical Association) |
| 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) |