Dealing with risks in patient care
Quality management
Dipl.-Math. Nicola Ungermann
Leitung Qualitäts- und Risikomanagement
Mauerfeldchen 25
52146 Würselen
Phone:
02405
-62-7876
Mail:
ed.mukinilksaamniehr@nnamregnu.alocin
Geschäftsführung, Krankenhausdirektorium, Ärztliches Direktorium, Qualitäts- und Risikomanagement, Betriebsrat, Controlling, Hygiene
Conference frequency: quartalsweise
Risk management
Nicola Ungermann
Leitung Qualitäts- und Risikomanagement
Phone:
02405
-62-7876
Fax: 02405-62-3199
Mail:
ed.mukinilksaamniehr@nnamregnu.alocin
Geschäftsführung, Krankenhausdirektorium, Ärztliches Direktorium, Qualitäts- und Risikomanagement, Betriebsrat, Controlling, Hygiene
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Brandschutz und Notfallplanung (KAEP) (01.04.2023) |
| RM05 |
Pain management Schmerztherapie (01.03.2022) |
| RM06 |
Fall prophylaxis Sturz (12.01.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Information zum ExpertenstandardDekubitusprophylaxe in der Pflege (06.05.2021) |
| RM08 |
Regulated handling of custodial measures VA Freiheitsentziehende Maßnahmen (03.04.2023) |
| 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 OP Checkliste (01.08.2024) |
| RM15 |
Preoperative, complete presentation of necessary findings Patientenevaluierung (07.01.2020) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Patientenarmbänder (06.08.2024) |
| RM17 |
Standards for recovery and postoperative care diverse SOPS für den AWR (01.10.2024) |
| RM18 |
Discharge management Entlassmanagement (13.08.2024) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Weiterentwicklung der OP Checkliste; Abarbeitung der Punkte der Aktion Patientensicherheit
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 17.03.2023 |
| IF02 |
Internal evaluation of the received reports taken bei Bedarf |
| 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 Associations, North Rhine-Westphalia Hospital Association, North Rhine and Westphalia-Lippe Associations of Statutory Health Insurance Physicians, German Medical Association) |