Dealing with risks in patient care

Quality management

Dr. med. Susanne Mikle

Qualitätsmanagementbeauftragte

In der Schornau 23-25
44892 Bochum

Phone: 0234 -299-4007
Mail: ed.muhcob-kk@mq

Geschäftsführung Pflegedirektion Pflegedienst Ärztlicher Dienst Betriebsrat HR-Management Projektmanagement Qualitäts- und Risikomanagement Unternehmensentwicklung

Conference frequency: quartalsweise

Risk management

Susanne Mikle

Qualitätsmanagementbeauftragte

In der Schornau 23-25
44892 Bochum

Phone: 0234 -299-4007
Fax: 0234-299-4099
Mail: ed.muhcob-kk@mq

Geschäftsführung Pflegedirektion Pflegedienst Ärztlicher Dienst Betriebsrat HR-Management Projektmanagement Qualitäts- und Risikomanagement Unternehmensentwicklung

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

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

Dr. Susanne Mikle (25.10.2024)

RM02

Regular further education and training measures

RM03

Employee surveys

RM04

Clinical emergency management

Dr. Susanne Mikle (25.10.2024)

RM05

Pain management

Alexander von Busch (24.10.2023)

RM06

Fall prophylaxis

Matthias Birkner (10.10.2023)

RM07

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

Matthias Birkner Thomas Eckel (09.01.2023)

RM08

Regulated handling of custodial measures

Matthias Birkner (04.09.2024)

RM09

Regulated handling of occurring malfunctions of devices

Michael Jakobs (27.04.2023)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Tumorkonferenzen
  • Mortalitäts- und Morbiditätskonferenzen
  • Pathologiebesprechungen
  • 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

OP-Koordinatoren (07.08.2024)

RM15

Preoperative, complete presentation of necessary findings

Matthias Birkner (08.09.2022)

RM16

Procedure to avoid procedural and patient mix-ups

Univ.-Prof. Dr. Kirsten Schmieder (10.02.2022)

RM17

Standards for recovery and postoperative care

Dr. Susanne Mikle (25.10.2024)

RM18

Discharge management

Susanne Mikle (10.04.2024)

Fault reporting systems

Conference committee

Conference frequency: bei Bedarf

Measures

Frühwarnsystem zur Erhöhung der Patientensicherheit Ziel des Fehlermeldesystems ist die Identifizierung von Risiken in der Patientenversorgung und deren unterstützenden Prozessen, sowie die Auswahl und Einleitung von geeigneten Maßnahmen zur Risikominimierung

No. Explanation
IF01

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

As of: 05.09.2022

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 monatlich

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)