Dealing with risks in patient care
Quality management
Kathrin Kalinke
Qualitätsmanagementbeauftragte
Vinzenz-Pallotti-Straße 20
51429 Bergisch-Gladbach-Bensberg
Phone:
02204
-41-5074
Mail:
ed.greb-niehr-nekinilk-ofg@eknilak.nirhtak
Regionaldirektion, kaufmännische Direktion, ärztliche Direktion, Pflegedirektion, Qualitätsmanagementbeauftragte bei Bedarf
Conference frequency: monatlich
Risk management
Kathrin Kalinke
Qualitätsmanagementbeauftragte
Phone:
02204
-41-5074
Fax: 02204-41-2001
Mail:
ed.greb-niehr-nekinilk-ofg@eknilak.nirhtak
Das CIRS-Team setzt sich aus MA unterschiedlichster Berufsgruppen interprofessionell, unter Leitung der Qualitätsmanagementbeauftragten, zusammen.
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Organisationshandbuch (15.12.2021) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Organisationshandbuch (15.12.2021) |
| RM05 |
Pain management Organisationshandbuch (15.12.2021) |
| RM06 |
Fall prophylaxis Organisationshandbuch (15.12.2021) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Organisationshandbuch (15.12.2021) |
| RM08 |
Regulated handling of custodial measures Organisationshandbuch (15.12.2021) |
| RM09 |
Regulated handling of occurring malfunctions of devices Organisationshandbuch (15.12.2021) |
| 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 (15.12.2021) |
| RM15 |
Preoperative, complete presentation of necessary findings Organisationshandbuch (15.12.2021) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Organisationshandbuch (15.12.2021) |
| RM17 |
Standards for recovery and postoperative care Organisationshandbuch (15.12.2021) |
| RM18 |
Discharge management Organisationshandbuch (15.12.2021) |
Fault reporting systems
Conference committee
Conference frequency: quartalsweise
Measures
Das Fehlermanagement ist nach den Anforderungen der DIN EN ISO 9001:2015 aufgebaut.
| No. | Explanation |
|---|---|
| IF02 |
Internal evaluation of the received reports taken halbjährlich |
| 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: quartalsweise
| No. | Explanation |
|---|---|
|
Other |
|
| EF06 |
CIRS NRW (North Rhine and Westphalia-Lippe Medical Chambers, North Rhine Westphalia Hospital Association, North Rhine and Westphalia-Lippe Association of Statutory Health Insurance Doctors, German Medical Association, National Association of Statutory Hea |