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

  • 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 (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