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

Überwachung Schmerztherapie (01.03.2022)

RM06

Fall prophylaxis

Sturzrisikoeinschätzung (01.07.2017)

RM07

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

Information zum Expertenstandard Dekubitusprophylaxe in der Pflege (05.05.2020)

RM08

Regulated handling of custodial measures

VA Freiheitsentziehende Maßnahmen (03.04.2023)

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

RM16

Procedure to avoid procedural and patient mix-ups

Patientenarmbänder (01.07.2017)

RM17

Standards for recovery and postoperative care

diverse SOPS für den AWR (03.12.2018)

RM18

Discharge management

Anleitung zum Entlassmanagement (26.02.2018)

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 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