Quantity performed	9
Exception?	No exception
Für diesen Leistungsbereich lag auf Grund der mit der Covid19-Pandemie verbundenen deutlichen Einschränkungen die Anzahl der Eingriffe in den Jahren 2020 bis 2022 auf einem niedrigen Niveau (§ 4 Abs. 2 Satz 4 Mm-R).

Complex operations on the pancreatic organ system

Quantity performed	11
Exception?	No exception

Knee joint total endoprostheses

Quantity performed	168
Exception?	No exception

Minimum quantities forecast

Complex interventions on the organ system esophagus for adults

Overall result forecast presentation:	yes
Quantity performed reporting year:	9
Quantity forecast year:	7
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:	11
Quantity forecast year:	12
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:	168
Quantity forecast year:	191
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:	255
Quantity forecast year:	289
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Thoracic surgical treatment of lung cancer in adults

Overall result forecast presentation:	yes
Quantity performed reporting year:	26
Quantity forecast year:	41
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
CQ06	Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 2

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

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

Number	Group
101	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*
75	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
75	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
Measures
- Review
  Recommendations for dealing with/processing cases that have occurred
  Last review of the measure
  18.09.2023 17:41:22

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

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

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)

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

Bereitstellung einer geeigneten Infrastruktur zur Sicherstellung einer fehlerfreien Zubereitung
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)
Sonstige_elektronische_Unterstuetzung

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)

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 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

Das SKD verfügt über zahlreiche Professoren, Dozenten und Lehrbeauftragte, welche an verschieden Hochschulen und Universitäten in Deutschland und anderen Ländern unterrichten. Die Klinik für Dermatologie ist Hochschulklinik der Medizinischen Hochschule Bandenburg Theodor Fontane.

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

Das Klinikum verfügt über Professuren, Dozenturen und Lehrbeauftragungen an verschiedenen Fachhochschulen in mehreren Bundesländern.

FL03 - Student training (clinical traineeship / internship year)

Explanation

In allen Kliniken und Instituten unseres Hauses werden Famulanten und PJ-Studierende während ihres gesamten klinischen Abschnittes ausgebildet. Ziel ist die umfassende klinische Ausbildung der Studenten zu Ärzten und die Einbringung der klinischen Kompetenzen in den letzten Studienabschnitt.

FL04 - Project-related cooperation with colleges and universities

Explanation

Das SKD ist akademisches Lehrkrankenhaus mit Hochschulabteilungen der Medizinischen Hochschule Brandenburg und arbeitet auf nationaler und internationaler Ebene mit Universitäten im Rahmen von Forschungsvorhaben und geförderten Projekten (z.B. BMBF, EU) zusammen.

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

Explanation

Das SKD mit seinem Zentrum für klinische Studien nahm an Phase I/II Studien nach AMG teil. Phase I/II Studien nach AMG sind in Planung. Der größte Teil der Studien wird in Kliniken für Dermatologie, Innere Medizin, Frauenheilkunde und Urologie durchgeführt.

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

Explanation

Das SKD nahm mit seinem Zentrum für klinische Studien an Phase III/IV Studien nach AMG teil. Phase III/IV Studie nach AMG sind in Planung. Der größte Teil der Studien wird in den Kliniken für Dermatologie, Innere Medizin, Frauenheilkunde und Urologie durchgeführt.

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

Explanation

Das SKD nahm mit seinem Zentrum für klinische Studien an Registerstudien und nicht interventionellen Studien (NIS) teil. Weiterhin befanden sich nicht interventionelle Studien (NIS) in der Planungsphase.

FL08 - Editors of scientific journals/textbooks

Explanation

Wissenschaftliche Erkenntnisse und Forschungsergebnisse werden regelhaft in begutachteten nationalen und internationalen Fachjournalen veröffentlicht. Obligat ist ebenfalls die Mitarbeit in Herausgebergremien und die Tätigkeit als Reviewer.

FL09 - Doctoral supervision

Explanation

Die Betreuung von Doktoranden ist ein Selbstverständnis am SKD. Gleichzeitig werden Habilitationen unterstützt und Diplomanden betreut.

Training

Training in other healing professions

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

Comment

In unserer staatlich anerkannten Pflegeschule wird zum 01. September jedes Jahres die dreijährige generalisierte Ausbildung zur Pflegefachfrau/ zum Pflegefachmann angeboten.

HB10 - Midwife (m/f)

Comment

Das Klinikum Dessau ist Ausbildungsträger für die praktische Hebammenausbildung in Kooperation mit der Hebammenschule am Universitätsklinikum Magdeburg.

HB12 - Medical technical laboratory assistant (MTLA) (m/f)