Overall result forecast presentation:	yes
Quantity performed reporting year:	176
Quantity forecast year:	187
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:	13
Quantity forecast year:	14
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:	no
Quantity performed reporting year:	1
Quantity forecast year:	1
Examination by state associations?	no
Exemption?	no
Result of the examination by the federal state authorities?	no
Transitional arrangement?	no

Surgical treatment of breast cancer (mamma surgery)

Overall result forecast presentation:	yes
Quantity performed reporting year:	12
Quantity forecast year:	13
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
CQ07	Measures for quality assurance in the care of pre-term and full-term neonates – perinatal focus
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)

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
78	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*
68	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
52	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

einzelne Bestandteile des Schutzkonzeptes sind implementiert, Gesamtkonzept befindet sich jedoch noch im Aufbau

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

DMS Roxtra

31.12.2022

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

DMS Roxtra

31.12.2022

SOP on good prescription practices

DMS Roxtra

31.12.2022

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®)

Concepts for ensuring the error-free preparation of medications

Zubereitung durch pharmazeutisches Personal

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)

Electronic documentation of the administration of drugs

Measures to minimise medication errors

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)
Fallbesprechungen

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

Diverse Dozenten und Lehrbeauftragungen an Hochschulen und Universitäten der einzelnen Chefärzte/innen entnehmen Sie bitte den entsprechenden Fachabteilungen.

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

Diverse Dozenten und Lehrbeauftragungen an Fachhochschulen der einzelnen Chefärzte/innen entnehmen Sie bitte den entsprechenden Fachabteilungen.

FL03 - Student training (clinical traineeship / internship year)

Explanation

Wöchentliche PJ-Seminare zur Fortbildung von Studierenden im Praktischen Jahr und während der Famulatur am CvBK (Akademisches Lehrkrankenhaus der Martin-Luther-Universität Halle-Wittenberg), fachärztliche Prüfungstätigkeit im mündlichen Staatsexamen und in Äquivalenzprüfungen für ausländische Ärzte

FL04 - Project-related cooperation with colleges and universities

Explanation

Kooperation der Hochschule Merseburg (FH) und der Carl-von-Basedow-Klinikum Saalekreis gGmbH. Kooperation Hämatologie und Onkologie: Mitglied im Krukenberg-Krebszentrum Halle, Kooperationsvertrag mit Universitärem Krebszentrum Leipzig (UCCL); weitere Koop. entn. Sie bitte den einz. Fachabteilungen

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

Explanation

Weitere Studien entnehmen Sie bitte den entsprechenden Fachabteilungen.

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

Explanation

APAF; TIM-HF; ETNA-AF; ETNA-VTE; HYDRA-ACS; XARENO; SCAN, 2013, Ende 2015; TIGRIS, 2013, ongoing; Ischemia, 2012, Ende 2015; TIM-HF, 2015, ongoing; NOFRETETE, ongoing; CLL Register, Ende 2018; weitere Studien entnehmen Sie bitte den entsprechenden Fachabteilungen.

FL08 - Editors of scientific journals/textbooks

Explanation

Diverse Herausgeberschaften bedeutender Journale und Lehrbücher der einzelnen Chefärzte/innen entnehmen Sie bitte den einzelnen Fachabteilungen.

FL09 - Doctoral supervision

Explanation

10 Doktoranden (in Kooperation mit Martin-Luther-Universität Halle-Wittenberg) und 2 Doktoranden (in Kooperation mit Otto von Guericke Universität Magdeburg); weitere Doktorandenbetreuungen entnehmen Sie bitte den entsprechenden Fachabteilungen.

Training

Training in other healing professions

HB07 - Surgical technical assistant (m/f)

Comment

Die Ausbildung vermittelt den SchülerInnen entsprechend dem allgemein anerkannten Stand technischer, medizinischer und weiterer bezugswissenschaftlicher Erkenntnisse fachliche, personelle, soziale und methodische Kompetenzen für die verantwortliche Mitwirkung in operativen Bereichen, Notaufnahme usw

HB15 - Anaesthesia technical assistant (m/f)

Comment

Im Mittelpunkt der Aufgabengebiete der OTA/ATA stehen die Mithilfe bei der Vorbereitung, Durchführung und Nachbereitung von Maßnahmen der medizinischen Diagnostik und Therapie und die umfassende Betreuung der Patientinnen und Patienten in diesen Arbeitsbereichen

HB19 - Nursing professionals

Comment

Die dreijährige Ausbildung erfolgt an unserem Bildungszentrum für Gesundheitsberufe entsprechend den gesetzlichen Regelungen für Pflegeberufe und vermittelt mit ihrem Curriculum notwendigen Fähigkeiten und Kompetenzen zur Ausübung des Pflegeberufes

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

Comment

Betreut vom jungen Erwachsenen bis zum alten Menschen. Hat beobachtende, überwachende und gesundheitserzieherische Aufgaben,vermittelnde Funktion in Zusammenarbeit mit den Ärztinnen/Ärzten. Verantwortlich für die Assistenz und Durchführung ärztlicher Anordnungen, Pflegeplanung und Pflegeberatung.

HB10 - Midwife (m/f)

Comment

Das CvBK Klinikum stellt Praktikumstellen in Kooperation mit dem Ausbildungszentrum für Gesundheitsberufe an der Martin-Luther-Universität Halle/Wittenberg zur Verfügung und übernimmt die Praxisanleitung

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