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Elisabeth Krankenhaus Recklinghausen

Dealing with risks in patient care

Quality management

Responsible person

Sabine Reppin

Qualitätsmanagementbeauftragte

Röntgenstr. 10
45661 Recklinghausen

Phone: 02361 -601-119
Mail: ed.enilnoke@nipper.enibas

Steering committee

Projektsteuerungsgruppe: Geschäftsführung, Mitarbeitervertretung, Medizinische Fachbereiche, Pflegedienst, Qualitätsmanagement, Risikomanagement, Seelsorge

Conference frequency: halbjährlich

Risk management

Responsible person

Boris Mönter

Oberarzt Geriatrie/Neurologie

Röntgenstr. 10
45661 Recklinghausen

Phone: 02361 -601-6441
Fax: 02361-601-299
Mail: ed.enilnoke@retneom.sirob

Steering committee

Controlling, Geschäftsführung, Medizinische Fachbereiche, Pflegedienst, Qualitätsmanagement, Stabsstelle Klinisches Risikomanagement. Bei Bedarf werden weitere Abteilungen eingeladen.

Conference frequency: quartalsweise

Risk management instruments and measures

Instruments and measures

No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Rahmenkonzept Risikomanagement (11.10.2024)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Medizinischer Notfall (15 Dokumente) (26.07.2024)
RM05	Pain management Behandlung von Schmerzpatienten (08.03.2024)
RM06	Fall prophylaxis Sturzprophylaxe (17.02.2024)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusprophylaxe (29.01.2024)
RM08	Regulated handling of custodial measures Verfahrensanweisung Fixierung (18.09.2023)
RM09	Regulated handling of occurring malfunctions of devices Organisationshandbuch Medizintechnik (24.10.2023)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Palliativbesprechungen Klinische Falldarstellung
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 Reorganisation; Patienten Blut Management PBM (5 Dokumente); Sicherheits-Checkliste ZOP Team-Time-Out (ORBIS) (24.05.2024)
RM16	Procedure to avoid procedural and patient mix-ups Aufnahme eines Patienten; Patientenidentifikation (16.04.2024)
RM17	Standards for recovery and postoperative care Aufnahme und Überwachung eines ambulanten Patienten im Zentrum für ambulantes Operieren (12.06.2024)
RM18	Discharge management Konzept Entlassmanagement (16.03.2023)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Patientenarmbänder

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 06.07.2023
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 jährlich

No.

Explanation

IF01

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

As of: 06.07.2023

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 jährlich

Across all institutions

Conference committee

Conference frequency: quartalsweise

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)