Niels-Stensen-Kliniken Marienhospital Ankum-Bersenbrück GmbH

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

Risikomanagement-Handbuch Niels-Stensen-Kliniken, Dokumenten-Nr.: 016369 (21.11.2023)

Clinical emergency management

Verfahrensanweisung Notfallmanagement MHA, Dokumenten-Nr.: 000817 (25.10.2023)

Pain management

Leitlinie Akutschmerztherapie NSK, Dokumenten-Nr.: 004684 (24.08.2021)

Fall prophylaxis

Standard Sturzprophylaxe MHA, Dokumenten-Nr.: 010317 (13.07.2020)

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

Standard Dekubitusprophylaxe MHA, Dokumenten-Nr.: 000855 (13.07.2020)

Regulated handling of custodial measures

Freiheitsentziehende Maßnahmen NSK, Dokumenten-Nr.: 014967 (11.09.2023)

Regulated handling of occurring malfunctions of devices

Verfahrensanweisung Meldung von Vorkommnissen mit Medizinprodukten NSK, Dokumenten-Nr.: 013311 (12.12.2022)

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

• Mortalitäts- und Morbiditätskonferenzen

Use of standardised information sheets

Application of standardised surgical check lists

Procedure to avoid procedural and patient mix-ups

OP-Sicherheits-Checkliste MHA, Dokumenten-Nr.: 013835 (27.10.2021)

Standards for recovery and postoperative care

Verfahrensanweisungen Aufwachraum MHA, Dokumenten-Nr.: 008182 (13.07.2020)

Discharge management

Verfahrensanweisung Entlassungsmanagement MHA, Dokumenten-Nr.: 013695 (13.07.2020)

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

As of: 05.07.2023

Internal evaluation of the received reports

taken monatlich

Training of employees in handling the error reporting system and in implementing the findings from the error reporting system

taken bei Bedarf

KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association)