Overall result forecast presentation:	yes
Quantity performed reporting year:	611
Quantity forecast year:	698
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
74	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*
11	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
11	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
- Prevention
  
  Special requirements for the selection of persons

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

bei Einsatz der elektronischen Patientenkurve und Medication

30.08.2022

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)

VA-06 Umgang mit Arzneimittel 06-00 RKH

30.04.2023

SOP on good prescription practices

AA perioperative Analgesie AWR ZAG BFT 01-00 OKM Anä

02.06.2014

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)
MIMI Pharmindex

Measures to minimise medication errors

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 Information der Aktuellen Rote Hand Briefe, bei Lieferdefekten und bei Umstellung der Präparate und Umstellung auf verwechlungssichere Adapter

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
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

Prof. Dr. med. B. Fink - Professur für Orthopädie -- Universitätsklinikum Hamburg-Eppendorf apl. Prof Dr. med. M. Haerle - Professur für Plastische Chirurgie -- Eberhard Karls Universität Tübingen Prof. Dr. med. P. Schuster - Associate Professor in Orthopädie & Unfallchirurgie -- PMU Salzburg

FL04 - Project-related cooperation with colleges and universities

Explanation

Institut für Pflegewissenschaft und -praxis der Paracelsus Medizinischen Privatuniversität, Salzburg

FL03 - Student training (clinical traineeship / internship year)

Explanation

Medizinstudium; Berufsbegleitendes Studium der Pflege

Training

Training in other healing professions

HB19 - Nursing professionals

Comment

Pflegeausbildung über RKH-Berufsfachschule für Pflege der Kliniken Ludwigsburg Bietigheim GmbH

HB20 - Nursing professional B. Sc.

Comment

Studium der Pflegewissenschaft in Kooperation mit Paracelsus Medizinische Privatuniversität Salzburg

HB07 - Surgical technical assistant (m/f)

Comment

Kooperation mit Ausbildungsstätte

HB17 - Auxiliary nurse (m/f)

Comment

Kooperation mit Ausbildungsstätte

HB15 - Anaesthesia technical assistant (m/f)

Comment

Kooperation mit Ausbildungsstätte

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

Comment

Pflegeausbildung und Studium der Pflegewissenschaft über RKH-Berufsfachschule für Pflege der Kliniken Ludwigsburg-Bietigheim gGmbH

HB03 - Physical therapist / physiotherapist (m/f)

Comment

Kooperation mit Ausbildungsstätte

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 12
- Additional staff: 8
- Explanations: weitere 8 Köpfe , die nicht über die Qualifikation Apotheker oder Pharmatechnische Assistenz verfügen
- Nursing staff regulation

Service contact persons

Customer feedback management

Ellen Locher

Mitarbeiterin Qualitätsmanagement - Beschwerdemanagement

Kurt-Lindemann-Weg 10
71706 Markgröningen

Phone: 07141 -99-60048
Mail: ed.tiehdnuseg-hkr@rehcol.nelle

Ulrich Schuler

Mitarbeiter Qualitätsmanagement - Beschwerdemanagement

Kurt-Lindemann-Weg 10
71706 Markgröningen

Phone: 07141 -99-60047
Mail: ed.tiehdnuseg-hkr@reluhcs.hcirlu

Quality management

Thorsten Hauptvogel

Abteilungsleiter Qualitätsmanagement

Kurt-Lindemann-Weg 10
71706 Markgröningen

Phone: 07141 -99-60042
Mail: ed.tiehdnuseg-hkr@legovtpuah.netsroht

Hygiene officer

Prof. Dr. Jörg Martin

Geschäftsführer

Kurt-Lindemann-Weg 10
71706 Markgröningen

Phone: 07141 -99-66001
Mail: ed.tiehdnuseg-hkr@lapoT.leugneS

Responsible for drug therapy

Ellen Locher

Patientensicherheitsbeauftragte, klinisches Risikomanagement

Kurt-Lindemann-Weg 10
71706 Markgröningen

Phone: 07141 -9960048-
Mail: ed.tiehdnuseg-hkr@rehcoL.nellE

Accessibility Officer

Bernhard Freitag

Bereichsleitung Service Pflege

Kurt-Lindemann-Weg 10
71706 Markgröningen

Phone: 07145 -91-54490
Mail: ed.tiehdnuseg-hkr@gatierf.drahnreb

Company

General contact details of the hospital

Kurt-Lindemann-Weg 10
71706 Markgröningen

Phone: 07145-91-0
Fax: 07141-99-60019
Mail: ed.tiehdnuseg-hkr@mko.ofni

Nursing service management

Bernhard Klink

Direktor für Pflege- und Prozessmanagement

Kurt-Lindemann-Weg 10
71706 Markgröningen

Phone: 07145 -91-53400
Mail: ed.tiehdnuseg-hkr@ttoille.arik

Head of administration

Prof. Dr. Jörg Martin

Geschäftsführer des Klinikverbundes RKH Regionale Kliniken Holding und Services GmbH (bis 31.09.2024)

Kurt-Lindemann-Weg 10
71706 Markgröningen

Phone: 07141 -99-66001
Mail: ed.tiehdnuseg-hkr@rreud.ailuj

Olaf Sporys

Klinikgeschäftsführer OKM

Kurt-Lindemann-Weg 10
71706 Markgröningen

Phone: 07145 -91-53001
Mail: ed.tiehdnuseg-hkr@dmelk.eleirbag

Responsible for the quality report in the hospital management

Olaf Sporys

Klinikgeschäftsführer OKM

Kurt-Lindemann-Weg 10
71706 Markgröningen

Phone: 07145 -91-53001
Mail: ed.tiehdnuseg-hkr@dmelk.eleirbag

Medical management

Dr. med. Jörg Richter

Ärztlicher Direktor des Zentrum für Sportorthopädie und spezielle Gelenkchirurgie

Kurt-Lindemann-Weg 10
71706 Markgröningen

Phone: 07145 -91-53209
Mail: ed.tiehdnuseg-hkr@eluer.ajni

PD Dr. med. Se-Chan Kim

(bis 31.03.2024) Ärztlicher Direktor des Zentrum für Anästhesie, Intensivmedizin und Schmerztherapie

Kurt-Lindemann-Weg 10
71706 Markgröningen

Phone: 07145 -91-53301
Mail: ed.tiehdnuseg-hkr@hcsrih.anna

Dr. med. Adriane Mayer

(von 01.04.2024 - bis 11.08.2024) Komm. Ärztliche Direktorin des Zentrum für Anästhesiologie, Intensivmedizin, Perioperative Medizin und Schmerztherapie

Kurt-Lindemann-Weg 10
71706 Markgröningen

Phone: 07145 -9153301-
Mail: ed.tiehdnuseg-hkr@hcsrih.anna

Professor Dr. med. Franziska Konrad

(ab 12.08.2024) Ärztliche Direktorin des Zentrum für Anästhesie, Intensivmedizin und Schmerztherapie

Kurt-Lindemann-Weg 10
71706 Markgröningen

Phone: 07145 -9153301-
Mail: ed.tiehdnuseg-hkr@hcsrih.anna

Prof. Dr. med. Bernd Fink

Ärztlicher Direktor des Zentrum für Endoprothetik, Fusschirurgie und Rheumaorthopädie

Kurt-Lindemann-Weg 10
71706 Markgröningen

Phone: 07145 -91-53201
Mail: ed.tiehdnuseg-hkr@kitehtorpodne.mko

Dr. med. Stefan Krebs

Ärztlicher Direktor des Wirbelsäulenzentrum für Neuroorthopädie, Rückenmarkverletzungen und Skoliosen