Overall result forecast presentation:	yes
Quantity performed reporting year:	97
Quantity forecast year:	113
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:	149
Quantity forecast year:	149
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
105	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*
105	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
105	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

Partnerklinik des Netzwerks ProBeweis, der Untersuchungsstelle für Gewaltopfer der Medizinischen Hochschule Hannover.

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

Use of standardised forms for drug medical history

QM-Handbuch

20.10.2021

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)
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
Teilnahme an einem einrichtungsübergreifenden Fehlermeldesystem (siehe Kapitel 12.2.3.2)
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
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

Teilnahme an Student- und Fachweiterbildungskursen für Ärzte

FL03 - Student training (clinical traineeship / internship year)

Explanation

In allen Abteilungen des Krankenhauses werden Famulaturen durchgeführt. Das Krankenhaus ist akademisches Lehrkrankenhaus der Universität Hamburg und Universität Rzeszów (Polen) und bildet PJ-Studenten aus.

FL04 - Project-related cooperation with colleges and universities

Explanation

Gastarztstatus Universitäres Herz- und Gefäßzentrum

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

Explanation

Biatain AG Reimbursement Study 2024 und 2005 randomisierte kontrollierte Multicenterestudie/BioStream HF-Postmarket Phase IV./Alphalong- Zulassungsstudie Phase III /Magmaris Register-Postmarket Phase IV/Xpedite-PhaseII/ Succsess PTA-Postmarket Phase IV/Selution 4SFA Phase III/Selution4BTK-Phase III

FL08 - Editors of scientific journals/textbooks

Explanation

Mitglied editorila Board Zeitschrift Gefäßchirurgie (Springer Verlag) und der Wundmnagment (MHP Verlag) / Mitglied und CoAutor AWMF S3 Leitliniengruppe Perioperative Antibiotikaprophylaxe Ernannter Vertreter und Co Autor der Deutschen Fachgesellschaft Gefäßchirurgie und Gefäßmedizin

FL09 - Doctoral supervision

Explanation

Gefäßchirurgie: 2 Doktorranden UKE

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

Dozent Fachtherapeut Chronische Wunde Schwerpunkt Diabetischer Fuß

Training

Training in other healing professions

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

Comment

Die Berufsbezeichnung hat sich geändert in Pflegefachfrau und Pflegefachmann

HB03 - Physical therapist / physiotherapist (m/f)

Comment

In Kooperation mit dem BB-Schulen

HB07 - Surgical technical assistant (m/f)

Comment

HB17 - Auxiliary nurse (m/f)

Comment

Seit 2023 ist die Berufsbezeichnung: Pflegeassistentin und Pflegeassistentin in Kooperation mit BBS Buchholz /Winsen

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

Comment

In Kooperation mit dem DRK

HB19 - Nursing professionals

Comment

GSBZ

HB20 - Nursing professional B. Sc.

Comment

BHH, HS Bremen, Ostfalia HS

HB09 - Speech therapist (m/f)

Comment

Schulische Ausbildung mit Praktikas, die in unseren Häusern durchgeführt werden können.

HB10 - Midwife (m/f)

Comment

In Kooperation mit dem UK Eppendorf

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 5
- Additional staff: 15
- Nursing staff regulation

Service contact persons

Patient advocates

Bernhard Jess

Patientenfürsprecher

Steinbecker Straße 44
21244 Buchholz in der Nordheide

Phone: 04181 -13-1944
Mail: ed.nesniw-suahneknark@rehcerpsreufnetneitap

Customer feedback management

Frau Antje Knöppke

QMB

Steinbecker Straße 44
21244 Buchholz in der Nordheide

Phone: 04171 -13-3009
Mail: ed.nesniw-suahneknark@ekppeonk.ejtna

Frau Andrea Hirche

QMB

Steinbecker Straße 44
21244 Buchholz in der Nordheide

Phone: 04181 -13-3003
Mail: ed.zlohhcub-suahneknark@ehcrih.aerdna

Quality management

Herr Christian Ponocny

Qualitätsmanager

Steinbecker Straße 44
21244 Buchholz in der Nordheide

Phone: 04171 -13-4004
Mail: ed.nesniw-suahneknark@ynconop.naitsirhc

Responsible for drug therapy

Frau Maren Köper

Apothekerin

Steinbecker Straße 44
21244 Buchholz in der Nordheide

Phone: 04171 -13-4081
Mail: ed.nesniw-suahneknark@repeok.neram

Accessibility Officer

Frau Anja Brandt

Schwerbindertenbeauftragter

Steinbecker Straße 44
21244 Buchholz in der Nordheide

Phone: 04181 -13-1010
Mail: ed.zlohhcub-suahneknark@tdnarb.ajna

Company

General contact details of the hospital

Steinbecker Straße 44
21244 Buchholz in der Nordheide

Phone: 04181-13-0
Mail: ed.zlohhcub-suahneknark@ofni

Nursing service management

Frau Sandra Kaltschmidt

Pflegedienstleitung

Steinbecker Straße 44
21244 Buchholz in der Nordheide

Phone: 04181 -13-1070
Mail: ed.zlohhcub-suahneknark@tdimhcstlak.ardnas

Herr Thomas Leonforte

Pflegedienstleitung

Steinbecker Straße 44
21244 Buchholz in der Nordheide

Phone: 04181 -13-3072
Mail: ed.zlohhcub-suahneknark@etrofnoel.samoht

Herr Jan Bergstein

Stellvertretende Pflegedienstleitung

Steinbecker Straße 44
21244 Buchholz in der Nordheide

Phone: 04181 -13-1523
Mail: ed.zlohhcub-suahneknark@nietsgreb.naj

Head of administration

Frau Dr. Franziska von Breunig

Geschäftsführerin

Steinbecker Straße 44
21244 Buchholz in der Nordheide

Phone: 4181 -13-1002
Mail: ed.zlohhcub-suahneknark@ginuerB.aksiznarF

Herr Kai Uffelmann

Geschäftsführer

Steinbecker Straße 44
21244 Buchholz in der Nordheide

Phone: 4181 -13-1004
Mail: ed.nesniw-suahneknark@nnamleffU.iaK

Herr Klaus-Jörg Bossow

Geschäftsführer

Steinbecker Straße 44
21244 Buchholz in der Nordheide

Phone: 4181 -13-1009
Mail: ed.zlohhcub-suahneknark@wossoB.greoJ-sualK

Responsible for the quality report in the hospital management

Dr. Franziska von Breunig

Ärztliche Geschäftsführung

Steinbecker Straße 44
21244 Buchholz in der Nordheide

Phone: 04181 -13-1002
Mail: ed.zlohhcub-suahneknark@ginuerb.aksiznarf

Medical management

Dr. Franziska von Breunig

ÄrztlicheGeschäftsführung

Steinbecker Straße 44
21244 Buchholz in der Nordheide

Phone: 04181 -13-1002
Mail: ed.zlohhcub-suahneknark@ginuerb.aksiznarf

Dr. Michael Scheruhn

Ärztlicher Direktor

Steinbecker Straße 44
21244 Buchholz in der Nordheide

Phone: 04181 -13-1201
Mail: ed.zlohhcuB-suahneknark@nhurehcs.leahcim

Dr. Werner Raut

Stellvertretender ärztlicher Direktor

Steinbecker Straße 44
21244 Buchholz in der Nordheide

Phone: 04181 -13-1301
Mail: ed.zlohhcub-suahneknark@tuar.renrew

IK number

IK: 260330112

Location number

Location number: 772558000

Certified centers & cooperations

Certified centers

DIN EN ISO 9001:2015

Certified until: 01.2027

Endoprothesenzentrum

Certified until: 10.2026

Traumzentrum

Certified until: 10.2026

Regionale Stroke Unit

Certified until: 07.2024

Cardiac Arrest Center

Certified until: 10.2026

Chest Pain Unit

Certified until: 08.2025

Brustkrebzentrum

Certified until: 03.2025

Darmkrebszentrum

Certified until: 09.2025

Familienfreundliches Unternehmen

Certified until: 12.2024

Certificates

Brustkrebszentrum

Certified until: 03.2028

Chest Pain Unit

Certified until: 08.2030

Darmkrebszentrum

Certified until: 09.2028

EndoProthetikZentrum

Certified until: 10.2026

family friendly

Certified until: 02.2027

Stroke Unit

Certified until: 07.2027

TraumaNetzwerk

Certified until: 09.2028

Cooperation

Hospital portrait for download