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Universitätsklinikum Bonn

Venusberg-Campus 1
53127 Bonn

Phone: 0228-287-0
Mail: ed.nnobku@ofni ed.nnobku@ofni ed.nnobku@ofni

https://www.ukbonn.de

Basic information

Number of beds: 1.306
Number of specialist departments: 28

Number of inpatient cases: 54.560
Number of partial inpatient cases: 2.625
Number of outpatient cases: 483.832

Hospital owners: Universitätsklinikum Bonn, AöR
Type of provider: öffentlich

University Hospital

Specialist departments

Services

Quality

External comparative quality assurance

Further information

External quality assurance according to state law
No participation

External quality assurance according to the DMP

Koronare Herzkrankheit (KHK)

Implementation of the minimum quantity agreement

Treatment area

Stem cell transplant

Quantity performed	55
Exception?	No exception

Surgical treatment of breast cancer (breast surgery)

Quantity performed	359
Exception?	No exception

Knee joint total endoprostheses

Quantity performed	146
Exception?	No exception

Complex interventions on the organ system esophagus for adults

Quantity performed	19
Exception?	No exception

Complex operations on the pancreatic organ system

Quantity performed	64
Exception?	No exception

Liver transplantation (including partial liver donation)

Quantity performed	20
Exception?	No exception

Kidney transplant (including living donation)

Quantity performed	19
Exception?	No exception
Das UKB geht langfristig von einer positiven Entwicklung der Fallzahlen aus. Die Leistungsgruppe Nierentransplantation wurde dem UKB in 2024 zugewiesen.

Thoracic surgical treatment of lung cancer in adults

Quantity performed	75
Exception?	No exception

Care of premature and mature infants (with an admission weight < 1250g)

Quantity performed	41
Exception?	No exception

Minimum quantities forecast

Stem cell transplant

Overall result forecast presentation:	yes
Quantity performed reporting year:	55
Quantity forecast year:	52
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Surgical treatment of breast cancer (mamma surgery)

Overall result forecast presentation:	yes
Quantity performed reporting year:	359
Quantity forecast year:	327
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Knee joint total endoprostheses

Overall result forecast presentation:	yes
Quantity performed reporting year:	146
Quantity forecast year:	158
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Complex interventions on the organ system esophagus for adults

Overall result forecast presentation:	yes
Quantity performed reporting year:	19
Quantity forecast year:	26
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:	64
Quantity forecast year:	66
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Liver transplantation (including partial liver donation)

Overall result forecast presentation:	yes
Quantity performed reporting year:	20
Quantity forecast year:	23
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Kidney transplantation (including living donation)

Overall result forecast presentation:	Pending lawsuit
Quantity performed reporting year:	19
Quantity forecast year:	14
Examination by state associations?	Pending lawsuit
Exemption?	yes
Result of the examination by the federal state authorities?	no
Transitional arrangement?	no

Thoracic surgical treatment of lung cancer in adults

Overall result forecast presentation:	yes
Quantity performed reporting year:	75
Quantity forecast year:	92
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Care of premature and mature infants (with an admission weight < 1250g)

Overall result forecast presentation:	yes
Quantity performed reporting year:	41
Quantity forecast year:	55
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
CQ01	Quality assurance measures for inpatient care with the indication abdominal aortic aneurysm
CQ02	Quality assurance measures for the inpatient care of children and adolescents with haemato-oncological diseases
CQ05	Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 1
CQ08	Measures for quality assurance of cardiac surgery care in children and adolescents according to Article 136, para. 1, sentence 1, no. 2 of the SGB V
CQ24	Quality assurance measures for allogeneic stem cell transplantation for multiple myeloma (valid until 30 June 2022)
CQ25	Measures for quality assurance in the performance of minimally invasive heart valve interventions pursuant to Article 136, para. 1, sentence 1, number 2 for hospitals licensed in accordance with Article 108 of the SGB V
CQ27	Guideline on quality assurance measures for inpatient care with bronchoscopic lung volume reduction procedures for severe emphysema (QS Guideline bronchoscopic LVR /QS-RL BLVR)
CQ28	Guideline on quality assurance measures for liposuction procedures for stage III lipedema (QS-RL Liposuction)
CQ03	Quality assurance measures for the implementation of positron emission tomography (PET) in hospitals for the indications non-small-cell lung cancer (NSCLC) and solid pulmonary nodules
CQ29	Measures for quality assurance of allogeneic stem cell transplantation with in-vitro processing (T-cell depletion via positive enrichment or negative selection) of the transplant in acute lymphoblastic leukaemia (ALL) and acute myeloid leukaemia (AML) in adults
CQ31	Guideline for the care of proximal femur fractures (QSFFx-RL)

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

Staffing levels in psychiatry and psychosomatics (PPP)

quarter Q1

Erwachsenenpsychiatrie

Day shift
Compliance with minimum requirements	yes
Level of implementation	90,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	103,19 %
Pflegefachpersonen	nein	83,08 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	ja	100,38 %
Spezialtherapeutinnen und Spezialtherapeuten	nein	84,92 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	194,44 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	ja	107,29 %
Night shift
Compliance with minimum requirements	no
Minimum requirement (full-time staff)	109
Current staffing levels (full-time staff)	123
Number of nights, subject to the minimum requirement	91

Psychosomatik

Day shift
Compliance with minimum requirements	yes
Level of implementation	124,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	199,64 %
Pflegefachpersonen	ja	155,72 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	nein	34,53 %
Spezialtherapeutinnen und Spezialtherapeuten	nein	29,9 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	nein	58,27 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	nein	0 %

quarter Q2

Erwachsenenpsychiatrie

Day shift
Compliance with minimum requirements	yes
Level of implementation	89,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	104,75 %
Pflegefachpersonen	nein	85,93 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	nein	78,09 %
Spezialtherapeutinnen und Spezialtherapeuten	nein	77,91 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	151,79 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	nein	94,53 %
Night shift
Compliance with minimum requirements	no
Minimum requirement (full-time staff)	111
Current staffing levels (full-time staff)	125
Number of nights, subject to the minimum requirement	91

Psychosomatik

Day shift
Compliance with minimum requirements	yes
Level of implementation	150,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	231,35 %
Pflegefachpersonen	ja	138,73 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	nein	35,38 %
Spezialtherapeutinnen und Spezialtherapeuten	ja	190,68 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	nein	55,44 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	ja	219 %

quarter Q3

No evidence of compliance has been provided

quarter Q4

Erwachsenenpsychiatrie

Day shift
Compliance with minimum requirements	yes
Level of implementation	89,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	101,02 %
Pflegefachpersonen	nein	89,54 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	nein	79,98 %
Spezialtherapeutinnen und Spezialtherapeuten	nein	79,6 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	102,91 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	nein	76,05 %
Night shift
Compliance with minimum requirements	no
Minimum requirement (full-time staff)	111
Current staffing levels (full-time staff)	122
Number of nights, subject to the minimum requirement	92

Psychosomatik

Day shift
Compliance with minimum requirements	yes
Level of implementation	143,0 %
Occupational group	Minimum requirements met	Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten	ja	186,32 %
Pflegefachpersonen	ja	153,56 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen	nein	35,64 %
Spezialtherapeutinnen und Spezialtherapeuten	ja	122,49 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten	ja	128,99 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen	ja	261,18 %

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

Number	Group
1492	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*
750	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
431	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? No
No care for children and young people

Die derzeitige Arbeit im Kinderschutz bezieht sich auf die Diagnostik, Behandlung und Versorgung von Kindern, die Opfer von (sexueller) Gewalt wurden und in der Klinik vorgestellt werden. Darunter fällt auch die Akkreditierung als Kinderschutzgruppe, die regelmäßige Schulung von Mitarbeitenden, die Fortbildung von Personal in diesem Bereich. Auch bzgl. der Erstellung von Schutzkonzepten für den Schutz von Kindern in unserer Klinik gibt es Expertise, allerdings kein ausgearbeitetes Schutzkonzept.

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

Teil des Anamnesebogens

01.01.2019

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)

Elektronische Verordnungssysteme

01.01.2019

Possibility of electronic prescription i.e. structured entry of active substances (or name of the preparation), form, dose, dose frequency (e.g. in the HIS, in prescription software)

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

Zubereitung durch pharmazeutisches Personal
Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen

Electronic support for the supply of patients with drugs

Vorhandensein von elektronischen Systemen zur Entscheidungsunterstützung (z.B. Meona®, Rpdoc®, AIDKlinik®, ID Medics® bzw. ID Diacos® Pharma)
Versorgung der Patientinnen und Patienten mit patientenindividuell abgepackten Arzneimitteln durch die Krankenhausapotheke (z.B. Unit-Dose-System)

Electronic documentation of the administration of drugs

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.