Dealing with risks in patient care
Quality management
Frau Kristina Riske
Qualitätsmanagement
Hospitalstraße 45 45
53840 Troisdorf
Phone:
02241
-801-109
Mail:
ed.enilno-ofg@eksir.anitsirk
Erweiterte Krankenhausbetriebsleitung und Qualitätsmanagement
Conference frequency: jährlich
Risk management
Kristina Riske
Qualitätsmanagement
Hospitalstraße 45 45
53840 Troisdorf
Phone:
02241
-801-109
Mail:
ed.enilno-ofg@eksir.anitsirk
Erweiterte Krankenhausbetriebsleitung und Qualitätsmanagement
Conference frequency: jährlich
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Organisationshandbuch (21.02.2023) |
| RM02 |
Regular further education and training measures |
| RM03 |
Employee surveys |
| RM04 |
Clinical emergency management Organisationshandbuch (17.04.2023) |
| RM05 |
Pain management Organisationshandbuch (26.09.2023) |
| RM06 |
Fall prophylaxis Organisationshandbuch (30.11.2023) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Organisationshandbuch (30.11.2023) |
| RM08 |
Regulated handling of custodial measures Organisationshandbuch (21.02.2023) |
| RM09 |
Regulated handling of occurring malfunctions of devices KRITIS Aufallkonzept über Medizintechnik (01.07.2024) |
| 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 Organisationshandbuch (21.02.2023) |
| RM15 |
Preoperative, complete presentation of necessary findings Organisationshandbuch (21.02.2023) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Organisationshandbuch (21.02.2023) |
| RM17 |
Standards for recovery and postoperative care Organisationshandbuch (22.02.2022) |
| RM18 |
Discharge management Organisationshandbuch (21.02.2023) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Erfassung, Bearbeitung und Nachverfolgung über Intrafox
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 27.03.2023 |
| 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 |
|---|---|
| EF02 |
CIRS Berlin (Berlin Medical Association, German Medical Association) |
| 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) |
| EF14 |
CIRS Health Care |