Rotkreuzklinikum München gGmbH

Nymphenburger Straße 163
80634 München

Phone: 089-13030
Mail: ed.krbmws@nehcneum-mukinilkzuerktor rotkreuzklinikum-muenchen@swmb... ed.krbmws@nehcneum-mukinilkzuerktor

https://www.rotkreuzklinikum-muenchen.de

Basic information

Number of beds: 435
Number of specialist departments: 16

Number of inpatient cases: 19.816
Number of partial inpatient cases: 489
Number of outpatient cases: 44.239

Hospital owners: Schwesternschaft München vom Bayerischen Roten Kreuz e.V.
Type of provider: freigemeinnützig

Academic teaching hospital

Specialist departments

Services

Quality

External comparative quality assurance

Further information

External quality assurance according to state law

Bezeichnung
Teilnahme externe Qualitätssicherung	yes

Quality of participation in the Disease Management Programme (DMP)
No participation

Implementation of the minimum quantity agreement

Treatment area

Surgical treatment of breast cancer (breast surgery)

Quantity performed	1.436
Exception?	No exception

Complex operations on the pancreatic organ system

Quantity performed	30
Exception?	No exception

Minimum quantities forecast

Surgical treatment of breast cancer (mamma surgery)

Overall result forecast presentation:	yes
Quantity performed reporting year:	1.436
Quantity forecast year:	1.425
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Complex operations on the pancreatic organ system

Overall result forecast presentation:	yes
Quantity performed reporting year:	30
Quantity forecast year:	28
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Implementation of resolutions of the Federal Joint Committee on quality assurance (G-BA)

No.	Explanation
CQ05	Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 1

Compliance with staffing requirements

Clarifying chat completed: no
Clarifying chat not completed: no
No participation in clarifying chat: no
Notification of non-fulfilment of nursing care not made: yes

Management of quality assurance for proximal femoral fracturet (QSFFx)

Full record of compliance maintained

Number of days shown	366
Days of non-performance	0
Number of minimum requirements not met	0

General minimum requirements

Minimum requirement	Days of non-performance
Trauma room	0
Availability	0
Computed tomography (CT)	0
Intensive care beds	0
Department of Surgery	0
Forwarding by air	0
Department of Internal Medicine	0
Intensive care beds with ventilator facilities	0
Emergency care training courses	0
Treatment prioritisation system (triage)	0
Responsibility for emergency care	0

Specific minimum requirements

Minimum requirement	Days of non-performance
Doctor on duty	0
Supervision by a medical specialist	0
Geriatric expertise	0
Operating room equipment	0
Post-operative physiotherapy	0
Independent organisational unit	0

Minimum requirements for process quality

Minimum requirement	Days of non-performance
SOP: Surgical procedures	0
SOP: Perioperative Planning	0
SOP: Capacity to consent	0
Standard Operating Procedure for the Management of Anticoagulants	0
SOP: Ortho-geriatric Care	0
SOP: Physiotherapy Measures	0
SOP: Patient-centred blood management	0

Further training
pursuant to Article 136b, para. 1, sentence 1, no. 1 of the SGB

Number	Group
129	Medical specialists (m/f) , psychological psychotherapists (m/f) and child and adolescent psychotherapists (m/f) who are subject to the obligation to undergo further training*
20	Number of medical specialists (m/f) from no. 1 who have completed a five-year period of further training and are therefore subject to the obligation to provide evidence
12	Number of those persons from no. 2 who have provided proof of further training according to Article 3 of the G-BA regulations

* according to the “Provisions of the Joint Federal Committee for the Further Training of Medical Specialists (m/f), Psychological Psychotherapists (m/f) and Child and Adolescent Psychotherapists (m/f) in Hospitals”

General information

Protection concept against (sexual) violence against children and young people

Advice on prevention and intervention in cases of violence and abuse

According to Section 4 (2) of the Quality Management Guideline, facilities must provide for the prevention of and intervention in cases of violence and abuse as part of their internal quality management. The aim is to prevent, recognise and respond appropriately to abuse and violence, particularly against vulnerable patient groups such as children and adolescents or people in need of help, and also to prevent it within the facility. The respective procedure is aligned with the size of the facility, the range of services and the patients in order to define customised solutions for sensitising the teams as well as other suitable preventative and interventional measures. These may include information materials, contact addresses, training/education, codes of conduct, recommendations for action/intervention plans or comprehensive protection concepts.

Is a protection concept in place? Yes
No care for children and young people

Commentary on the protection concept

Gemäß Teil A § 4 Absatz 2 in Verbindung mit Teil B Abschnitt I § 1 der Qualitätsmanagement-Richtlinie haben sich Einrichtungen, die Kinder und Jugendliche versorgen, gezielt mit der Prävention von und Intervention bei (sexueller) Gewalt und Missbrauch bei Kindern und Jugendlichen zu befassen (Risiko- und Gefährdungsanalyse) und – der Größe und Organisationsform der Einrichtung entsprechend – konkrete Schritte und Maßnahmen abzuleiten (Schutzkonzept). In diesem Abschnitt geben Krankenhäuser, die Kinder und Jugendliche versorgen, an, ob sie gemäß Teil A § 4 Absatz 2 in Verbindung mit Teil B Abschnitt I § 1 der Qualitätsmanagement-Richtlinie ein Schutzkonzept gegen (sexuelle) Gewalt bei Kindern und Jugendlichen aufweisen.

Drug therapy safety

Steering committee

Drug commission

Training of employees on AMTS related topics

Availability of appropriate, topic-specific informational materials for patients on AMTS e.g. for chronic diseases, for high-risk drugs, for children

Use of standardised forms for drug medical history

Alle QM/RM-Dokumente stehen über das elektronische Dokumentenlenkungssystem zur Verfügung

29.08.2024

Electronic support for the admission and anamnesis process (e.g. import of patient master data or medication plans, use of a drug knowledge database, input screen for drugs or anamnesis information)

Process description for an optimal medication process (e.g. drug anamnesis – prescription – patient information – drug delivery – drug application – documentation – therapy monitoring – result evaluation)

Alle QM/RM-Dokumente stehen über das elektronische Dokumentenlenkungssystem zur Verfügung

29.08.2024

SOP on good prescription practices

Alle QM/RM-Dokumente stehen über das elektronische Dokumentenlenkungssystem zur Verfügung

29.08.2024

Provision of one or more electronic drug information systems (e.g. Lauer-Taxe®, ifap klinikCenter®, Gelbe Liste®, Fachinfo-Service®)

Concepts for ensuring the error-free preparation of medications

Bereitstellung einer geeigneten Infrastruktur zur Sicherstellung einer fehlerfreien Zubereitung
Zubereitung durch pharmazeutisches Personal
Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen

Measures to minimise medication errors

Fallbesprechungen
Maßnahmen zur Vermeidung von Arzneimittelverwechslung
Spezielle AMTS-Visiten (z. B. pharmazeutische Visiten, antibiotic stewardship, Ernährung)
Teilnahme an einem einrichtungsübergreifenden Fehlermeldesystem (siehe Kapitel 12.2.3.2)

Measures to ensure seamless drug therapy after discharge

Aushändigung von arzneimittelbezogenen Informationen für die Weiterbehandlung und Anschlussversorgung der Patientin oder des Patienten im Rahmen eines (ggf. vorläufigen) Entlassbriefs
Aushändigung von Patienteninformationen zur Umsetzung von Therapieempfehlungen
Aushändigung des Medikationsplans
bei Bedarf Arzneimittel-Mitgabe oder Ausstellung von Entlassrezepten

Instruments and measures

The instruments and measures to promote drug therapy safety are presented with a focus on the typical procedures of the medication process in inpatient patient care. A special feature of the medication process in the inpatient environment is the transition management during admission and discharge. The instruments and measures listed below address structural elements, e.g. special IT equipment and work materials, as well as process aspects, such as work descriptions for particularly risky process steps or concepts for securing typical risk situations . In addition, proven measures to avoid or learn from medication errors can be specified. The hospital presents here which aspects it has already dealt with and which measures it has specifically implemented. The following aspects can be presented, if necessary using free text fields:
- Admission to hospital, including anamnesis
; Instruments and measures are presented for determining the old medication (drug history), the subsequent clinical assessment and the switch to the medication available in the hospital (house list), as well as for documenting both the patient's original medication and that for hospital treatment adapted medication.
- Medication process in the hospital
In this context, the following sub-processes are assumed as examples: drug history - prescription - patient information - drug delivery - drug use - documentation - therapy monitoring - result assessment. Instruments and measures for safe medication prescription can be presented, e.g. B. in terms of readability, clarity and completeness of the documentation, but also in terms of area of application, effectiveness, benefit-risk ratio, tolerability (including potential contraindications, interactions, etc.) and resource considerations. Information can also be provided to support reliable medication ordering, delivery and use or administration.
- Discharge
In particular, the measures taken by hospitals can be presented to ensure that information on drug therapy is structured and passed on to doctors and physicians providing further treatment, as well as the appropriate provision of patients with drug information, medication plans and medications. Drug prescriptions are made.

AMTS is the totality of measures to ensure an optimal medication process with the aim of reducing medication errors and thus avoidable risks for patients during drug therapy. A prerequisite for the successful implementation of these measures is that AMTS is practised as an integral part of daily routine in an interdisciplinary and multi-professional approach.

Special instrument-based equipment

Research & teaching

Job

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

Prof. Dr. M. Hentrich, Prof. Dr. W. Thasler (LMU) Prof. Dr. M. Pölcher, Prof. Dr. M. Braun, Prof. Dr. R. Kiefmann (TU München) Prof. Dr. C. von Bary (Med. Fakultät an Universität Regensburg)

FL03 - Student training (clinical traineeship / internship year)

Explanation

Lehrkrankenhaus der Technischen Universität München

FL04 - Project-related cooperation with colleges and universities

Explanation

Gemeinsame Projekte mit der Klinik für Strahlentherapie der TU München, sowie mit dem Zentrum für familiären Brust- und Eierstockkrebs der Frauenklinik TU München, Mitglied des Tumorzentrums München, Mentales Training in der Chirurgie

FL05 - Participation in multi-centre Phase I/II studies

Explanation

Aktuelles Studienangebot unter https://rotkreuzklinikum-muenchen.de/medizin-und-pflege/onkologisches-zentrum/studienzentrale/

FL06 - Participation in multi-centre phase III/IV studies

Explanation

Aktuelles Studienangebot unter https://rotkreuzklinikum-muenchen.de/medizin-und-pflege/onkologisches-zentrum/studienzentrale/

FL07 - Initiation and management of uni-centric/multi-centric clinical/scientific studies

Explanation

Aktuelles Studienangebot unter https://rotkreuzklinikum-muenchen.de/medizin-und-pflege/onkologisches-zentrum/studienzentrale/

FL09 - Doctoral supervision

Explanation

Prof. Dr. Marcus Hentrich, Prof. Dr. Michael Braun, Prof. Dr. Martin Pölcher, Prof. Dr. Wolfgang Thasler

Training

Training in other healing professions

HB01 - Nurse and health care worker (m/f)

Comment

Berufsfachschule für Krankenpflege der Schwesternschaft München vom BRK e.V., Studium angewandte Pflegewissenschaften mit der Hochschule München

HB02 - Health and paediatric nurse (m/f)

Comment

Berufsfachschule für Kinderkrankenpflege der Schwesternschaft München vom BRK e.V.

HB07 - Surgical technical assistant (m/f)

Comment

Ausbildungshaus für die SAN-AK München

HB15 - Anaesthesia technical assistant (m/f)

Comment

Ausbildungshaus für die SAN-AK München

HB19 - Nursing professionals

Comment

Berufsfachschule für Krankenpflege der Schwesternschaft München vom BRK e.V.

HB10 - Midwife (m/f)

Comment

Kooperation mit der Katholischen Stiftungshochschule, Praxiseinsatz Studium Hebamme Bsc.

HB18 - Emergency paramedics (m/f) (training period 3 years)

Comment

HB20 - Nursing professional B. Sc.

Comment

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 2
- Explanations: Ein Apotheker ist an einem Tag in der Woche im Haus zur Stationsarbeit. Zusätzlich werden Projekte im Bereich ABS bearbeitet. Es gibt zwei verantwortliche Apotheker in der Zytostatika-Herstellung.
- Nursing staff regulation