Dealing with risks in patient care

Quality management

Frau Sabrina Thumser

Qualitätsmanagement

Wilhelm-Busch Str. 9 9
53844 Troisdorf - Sieglar

Phone: 02241 -488-523
Mail: ed.frodsiort-nekinilk-ofg@resmuht.anirbas

erweiterte Krankenhausbetriebsleitung und Qualitätsmanagement

Conference frequency: jährlich

Risk management

Sabrina Thumser

Qualitätsmanagement

Phone: 02241 -488-523
Mail: ed.frodsiort-nekinilk-ofg@resmuht.anirbas

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

RM04

Clinical emergency management

Organisationshandbuch (14.06.2023)

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 Ausfallkonzepte über Medizintechnik (01.07.2024)

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

Organisationshandbuch (21.02.2023)

RM15

Preoperative, complete presentation of necessary findings

Organisationshandbuch (21.02.2023)

RM16

Procedure to avoid procedural and patient mix-ups

Wird über OP-Sicherheitscheckliste gewährleistet Team-Time-Out als weiteres Instrument zur Patientensicherheit (22.08.2023)

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 das Intrafox-Tool

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: monatlich

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