Dealing with risks in patient care
Quality management
M.A. Jennifer Jacobs
Qualitätsmanagementbeauftragte
Tenholter Str. 43
41812 Erkelenz
Phone:
02431
-89-2231
Mail:
ed.znelekre-kjh@sbocajj
Geschäftsführung, Ärztlicher Direktor, Pflegedirektor, Chefärzte, wie auch (Bereichs-) Leitungen und Ansprechpartnern in den zertifizierten Bereichen
Conference frequency: quartalsweise
Risk management
Jennifer Jacobs
Qualitätsmanagementbeauftragte
Phone:
02431
-89-2231
Fax: 02431-89-2218
Mail:
ed.znelekre-kjh@sbocajj
Geschäftsführung, Ärztlicher Direktor, Pflegedirektor, Chefärzte, wie auch (Bereichs-) Leitungen und Ansprechpartnern in den zertifizierten Bereichen
Conference frequency: quartalsweise
Risk management instruments and measures
| No. | Explanation |
|---|---|
| RM01 |
Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikopolitik und Risikomanagement (22.06.2022) |
| RM02 |
Regular further education and training measures |
| RM04 |
Clinical emergency management Risikopolitik und Risikomanagement (22.06.2022) |
| RM05 |
Pain management Risikopolitik und Risikomanagement (22.06.2022) |
| RM06 |
Fall prophylaxis Risikopolitik und Risikomanagement (22.06.2022) |
| RM07 |
Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Risikopolitik und Risikomanagement (22.06.2022) |
| RM08 |
Regulated handling of custodial measures Risikopolitik und Risikomanagement (22.06.2022) |
| RM09 |
Regulated handling of occurring malfunctions of devices Risikopolitik und Risikomanagement (22.06.2022) |
| 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 Risikopolitik und Risikomanagement (22.06.2022) |
| RM15 |
Preoperative, complete presentation of necessary findings Risikopolitik und Risikomanagement (22.06.2022) |
| RM16 |
Procedure to avoid procedural and patient mix-ups Umgang Patientenidentifikationsarmband (PIAb) (01.03.2023) |
| RM17 |
Standards for recovery and postoperative care Risikopolitik und Risikomanagement (22.06.2022) |
| RM18 |
Discharge management Risikopolitik und Risikomanagement (22.06.2022) |
Fault reporting systems
Conference committee
Conference frequency: monatlich
Measures
Fallbesprechungen zur Qualitätsverbesserung in den betroffenen Bereichen
| No. | Explanation |
|---|---|
| IF01 |
Documentation and procedural instructions for handling the error reporting system are available As of: 31.03.2022 |
| IF02 |
Internal evaluation of the received reports taken monatlich |
| IF03 |
Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken halbjährlich |
Conference committee
Conference frequency: monatlich
| No. | Explanation |
|---|---|
| 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) |