Overall result forecast presentation:	yes
Quantity performed reporting year:	698
Quantity forecast year:	746
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 participation

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: no

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

Number	Group
71	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*
14	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
9	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

Commentary on the protection concept

Gemäß § 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 § 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

Qualitätsmanagementhandbuch und Risikomanagementhandbuch

23.12.2022

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)

Qualitätsmanagementhandbuch und Risikomanagementhandbuch

23.12.2022

SOP on good prescription practices

Qualitätsmanagementhandbuch und Risikomanagementhandbuch

23.12.2022

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®)

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)
Internetportal der Lieferapotheke zur Medikamentenbestellung mit integrierter Arzneimittelliste

Electronic documentation of the administration of drugs

Measures to minimise medication errors

Maßnahmen zur Vermeidung von Arzneimittelverwechslung
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

FL03 - Student training (clinical traineeship / internship year)

Explanation

Famulaturen und Praktika in allen Kliniken möglich

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

Explanation

Klinik für Orthopädie: Kooperation mit Firma ZimmerBiomet (Allofit-IT-Studie); DFG Projekt ROGUS-PAD: "Robotorgeführtes Ultraschallsystem für periphere Arterielle Verschlusskrankheit (RoGUS-PAD).

FL08 - Editors of scientific journals/textbooks

Explanation

Wissenschaftliche Journal-Beiträge

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

Lehrbeauftragter an der FAU Erlangen-Nürnberg (Hr. Priv.-Doz. Dr. Anders); Lehrbeauftragter an der Paracelsus Medizinischen Privatuniversität Nürnberg (Hr. Prof. Dr. Biber); Lehrbeauftragter an der Universität zu Lübeck & Nationale Medizinische M.-I.-Pirogow-Uni. (Ukraine) (Hr. Prof. Dr. Kleemann)

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

Explanation

Multizentrische Studie: "Eine multizentrische prospektive randomisierte Studie zu Vergleich von Fissurektomie mit Anal Advancement Flap in der operativen Behandlung der chronischen Analfissur."

FL09 - Doctoral supervision

Explanation

In Zusammenarbeit mit der FAU Erlangen-Nürnberg, der Paracelsus Medizinische Privatuniversität Nürnberg und Universität zu Lübeck.

FL04 - Project-related cooperation with colleges and universities

Explanation

Entsprechend der Lehraufträge, Klinik für Orthopädie: FAU Erlangen-Nürnberg; Zusammenarbeit mit FOM-Hochschule Nürnberg und Evangelische Hochschule Nürnberg; Klinik für Viszeral- und Gefäßchirurgie: Zusammenarbeit mit der Universität und Technischen Hochschule Lübeck

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

Lehrbeauftragter an der FOM-Hochschule Nürnberg (Herr Dr. Wiendieck)

Training

Training in other healing professions

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

Comment

In Kooperation mit der Berufsfachschule für Gesundheits- und Krankenpflege vom BRK Nürnberg e. V. und der Klinik Hallerwiese.

HB03 - Physical therapist / physiotherapist (m/f)

Comment

In Form von Praktika.

HB06 - Occupational therapist (m/f)

Comment

In Form von Praktika.

HB20 - Nursing professional B. Sc.

Comment

In Kooperation mit verschiedenen Hochschulen.

HB19 - Nursing professionals

Comment

Kinästhetik, Stomaversorgung, Wundmanagement etc.

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

Comment

In Kooperation mit mehreren Rettungsdienstorganisationen.

HB07 - Surgical technical assistant (m/f)

Comment

In Kooperation mit der Universitätsklinik Erlangen.

Hospital staff
Pharmaceutical personnel
- Additional staff: 1
- Explanations: Kooperationsvertrag mit Lieferapotheke
- Nursing staff regulation

Service contact persons

Patient advocates

Andrea Pfitzinger

Hauptamtliche Patientenfürsprecherin und Mitarbeiterin Qualitäts- und Risikomanagement, Schwerpunkt Beschwerdemanagement

Kontumazgarten 4-19
90429 Nürnberg

Phone: 0911 -2728-6681
Mail: ed.kinilk-relre@rehcerpsreufnetneitap

Georg Klucken

Ehrenamtlicher Patientenfürsprecher

Kontumazgarten 4-19
90429 Nürnberg

Phone: 0911 -2728-6681
Mail: ed.kinilk-relre@rehcerpsreufnetneitap

Dr. Nicole Arnold

Hauptamtliche Patientenfürsprecherin und Mitarbeiterin Qualitäts- und Risikomanagement, Schwerpunkt Beschwerdemanagement

Kontumazgarten 4-19
90429 Nürnberg

Phone: 0911 -2728-6681
Mail: ed.kinilk-relre@rehcerpsreufnetneitap

Customer feedback management

Dr. Nicole Arnold

Mitarbeiterin Qualitäts- und Risikomanagement, Schwerpunkt Beschwerdemanagement

Kontumazgarten 4-19
90429 Nürnberg

Phone: 0911 -2728-446
Mail: ed.kinilk-relre@tnemeganamedrewhcseb

Andrea Pfitzinger

Mitarbeiterin Qualitäts- und Risikomanagement, Schwerpunkt Beschwerdemanagement

Kontumazgarten 4-19
90429 Nürnberg

Phone: 0911 -2728-449
Mail: ed.kinilk-relre@tnemeganamedrewhcseb

Quality management

Jürgen Grieß

Leitung Qualitäts- und Risikomanagement

Kontumazgarten 4-19
90429 Nürnberg

Phone: 0911 -2728-546
Mail: ed.kinilk-relre@tnemeganamsteatilauq

Hygiene officer

Prof. Dr. med. Roland Biber

Ärztlicher Direktor

Kontumazgarten 4-19
90429 Nürnberg

Phone: 0911 -2728-200
Mail: ed.kinilk-relre@eneigyh

Priv.-Doz. Dr. med. Jens Anders

Ärztlicher Direktor

Kontumazgarten 4-19
90429 Nürnberg

Phone: 0911 -2728-468
Mail: ed.kinilk-relre@eideapohtro

Responsible for drug therapy

Prof. Dr. med. Roland Biber

Ärztlicher Direktor

Kontumazgarten 4-19
90429 Nürnberg

Phone: 0911 -2728-200
Mail: ed.kinilk-relre@eigrurihcllafnu

Priv.-Doz. Dr. med. Jens Anders

Ärztlicher Direktor

Kontumazgarten 4-19
90429 Nürnberg

Phone: 0911 -2728-468
Mail: ed.kinilk-relre@eideapohtro

Accessibility Officer

Anja Saemann-Ischenko

Leitung Interne und externe Kommunikation / Unternehmensentwicklung

Kontumazgarten 4-19
90429 Nürnberg

Phone: 0911 -2728-479
Mail: ed.kinilk-relre@oknehcsi-nnameas.a

Company

General contact details of the hospital

Kontumazgarten 4-19
90429 Nürnberg

Phone: 0911-2728-0
Fax: 0911-2728-106
Mail: ed.kinilk-relre@ofni

Nursing service management

Dominic Weufen

Pflegedienstleitung (seit 01.02.2023)

Kontumazgarten 4-19
90429 Nürnberg

Phone: 0911 -2728-298
Mail: ed.kinilk-relre@gnutieltsneidegelfp

Birgit Bachhuber

Pflegedienstleitung (bis 31.01.2023)

Kontumazgarten 4-19
90429 Nürnberg

Phone: 0911 -2728-298
Mail: ed.kinilk-relre@gnutieltsneidegelfp

Head of administration

M. Cristina Della Sala-Möhrlein

Klinikmanagement

Kontumazgarten 4-19
90429 Nürnberg

Phone: 0911 -2728-102
Mail: ed.kinilk-relre@nielrheom-alas.c

Saba Dedjban

Kaufmännische Leitung

Kontumazgarten 4-19
90429 Nürnberg

Phone: 0911 -2728-104
Mail: ed.kinilk-relre@nabjded.s

Responsible for the quality report in the hospital management

Markus Stark

Geschäftsführer

Kontumazgarten 4-19
90429 Nürnberg

Phone: 0911 -2728-100
Mail: ed.kinilk-relre@gnurheufstfeahcseg

Medical management

Prof. Dr. med. Roland Biber

Ärztlicher Direktor

Kontumazgarten 4-19
90429 Nürnberg

Phone: 0911 -2728-200
Mail: ed.kinilk-relre@eigrurihcllafnu

Priv.-Doz. Dr. med. Jens Anders

Ärztlicher Direktor (bis 31.12.2022)

Kontumazgarten 4-19
90429 Nürnberg

Phone: 0911 -2728-468
Mail: ed.kinilk-relre@eideapohtro

Regional care obligation for psychiatry?

IK number

IK: 260950179

Location number

Location number: 771076000

Old location number: 771076000