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Katholisches Karl-Leisner Klinikum gGmbH Standort Marienhospital Kevelaer

Basilikastraße 55
47623 Kevelaer

Phone: 02832-100
Fax: 02832-10-1005
Mail: ed.elkk@kha.tairaterkes

http://www.kkle.de
  • Number of beds: 210
  • Number of specialist departments: 7
  • Number of inpatient cases: 8.812
  • Number of outpatient cases: 26.721
  • Hospital owners: Katholisches Karl-Leisner-Klinikum gGmbH Kleve
  • Type of provider: freigemeinnützig
External comparative quality assurance
Further information
  • External quality assurance according to state law
    No participation
  • Quality of participation in the Disease Management Programme (DMP)
    No participation
  • Implementation of the minimum quantity agreement
    No participation
No. Explanation
CQ01 Quality assurance measures for inpatient care with the indication abdominal aortic aneurysm
  • 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
Number Group
42 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*
39 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
28 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”

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.

  • Information über lokale Hilfsangebote, Sichtbarmachen in den Räumlichkeiten
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 commission

Verordnung von Arneimitteln

16.07.2022

Verordnung, Verabreichung, Arzneimitteltherapie

16.07.2022

Verordnung von Arzneimitteln

16.07.2022

  • Bereitstellung einer geeigneten Infrastruktur zur Sicherstellung einer fehlerfreien Zubereitung
  • Zubereitung durch pharmazeutisches Personal
  • Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen
  • Elektronische Unterstützung Medikationsprozess, AID-Klinik
  • Vorhandensein von elektronischen Systemen zur Entscheidungsunterstützung (z.B. Meona®, Rpdoc®, AIDKlinik®, ID Medics® bzw. ID Diacos® Pharma)
  • 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)
  • Elektronische Unterstützung im Medikationsprozess, AID-Klinik
  • 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
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.
Job
Explanation

Explanation

Unfallchirurgie

Training in other healing professions
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Hans Gerd Op de Hipt

Patientenfürsprecher

Basilikastraße 55
47623 Kevelaer

Phone: 02832 -10-0
Mail: ed.elkk@khm.ofnI

Gisela Dressel

Zentrale Beschwerdemanagerin

Basilikastraße 55
47623 Kevelaer

Phone: 02825 -535272361-
Mail: ed.elkk@lesserD.alesiG

Svenja Görtz

Leitung Qualitäts- und Risikomanagement

Basilikastraße 55
47623 Kevelaer

Phone: 02821 -490-1265
Mail: ed.elkk@ztreog.ajnevs

Prof. Dr. med. Volker Runde

Krankenhaushygienikerin

Basilikastraße 55
47623 Kevelaer

Phone: 02823 -891-115
Mail: ed.elkk@ednuR.rekloV

Prof. Dr. med. Volker Runde

Chefarzt

Basilikastraße 55
47623 Kevelaer

Phone: 02823 -891-115
Mail: ed.elkk@ednuR.rekloV

Maria Itrich

Leitung Sozialdienst

Basilikastraße 55
47623 Kevelaer

Phone: 02821 -490-7590
Mail: ed.elkk@hcirtI.airaM

Maria Itrich

Leitung Sozialdienst

Basilikastraße 55
47623 Kevelaer

Phone: 02821 -490-7590
Mail: ed.elkk@hcirtI.airaM

Basilikastraße 55
47623 Kevelaer

Phone: 02832-100
Fax: 02832-10-1005
Mail: ed.elkk@kha.tairaterkes

Markus Elisat

Pflegedienstleiter

Basilikastraße 55
47623 Kevelaer

Phone: 02832 -10-2201
Mail: ed.elkk@tasilE.sukraM

Sabine Dr. Kisselbach

Geschäftsführer

Basilikastraße 55
47623 Kevelaer

Phone: 02821 -490-1001
Mail: ed.elkk@hcablessiK.enibaS

Sabine Dr. Kisselbach

Geschäftsführer

Basilikastraße 55
47623 Kevelaer

Phone: 02821 -490-1001
Mail: ed.elkk@hcablessiK.enibaS

Prof. Dr. med. Volker Runde

Chefarzt

Basilikastraße 55
47623 Kevelaer

Phone: 02823 -891-115
Mail: ed.elkk@ednuR.rekloV

No

IK: 260511020

Location number: 772767000

Old location number: 772767000

Hospital portrait for download