Universitätsklinikum Regensburg

Franz-Josef-Strauß-Allee 11
93053 Regensburg

Phone: 0941-944-0
Mail: ed.rku@ofni ed.rku@ofni ed.rku@ofni

http://www.ukr.de

The main duties of a University Hospital are patient care, research and teaching. Each of these areas of responsibility requires highly committed members...

Basic information

Number of beds: 839
Number of specialist departments: 32

Number of inpatient cases: 29.510
Number of partial inpatient cases: 5.065
Number of outpatient cases: 180.737

Hospital owners: Rechtsfähige Anstalt des öffentlichen Rechts des Freistaates Bayern
Type of provider: öffentlich

University Hospital

Specialist departments

Services

Quality

External comparative quality assurance

Further information

External quality assurance according to state law

Bezeichnung
Teilnahme externe Qualitätssicherung	yes

Quality of participation in the Disease Management Programme (DMP)
No participation

Implementation of the minimum quantity agreement

Treatment area

Liver transplantation (including partial liver donation)

Quantity performed	38
Exception?	No exception

Kidney transplant (including living donation)

Quantity performed	66
Exception?	No exception

Knee joint total endoprostheses

Quantity performed	65
Exception?	No exception

Complex interventions on the organ system esophagus for adults

Quantity performed	27
Exception?	No exception

Complex operations on the pancreatic organ system

Quantity performed	72
Exception?	No exception

Stem cell transplant

Quantity performed	76
Exception?	No exception

Care of premature and mature infants (with an admission weight < 1250g)

Quantity performed	1
Exception?	No exception

Surgical treatment of breast cancer (breast surgery)

Quantity performed	1
Exception?	No exception
Der Eingriff erfolgte ausnahmsweise bei Vorliegen besonderer medizinischer Umstände. Eine reguläre Erbringung oder Planung dieser Leistung ist nicht vorgesehen.

Thoracic surgical treatment of lung cancer in adults

Quantity performed	117
Exception?	No exception

Minimum quantities forecast

Liver transplantation (including partial liver donation)

Overall result forecast presentation:	yes
Quantity performed reporting year:	38
Quantity forecast year:	38
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Kidney transplantation (including living donation)

Overall result forecast presentation:	yes
Quantity performed reporting year:	66
Quantity forecast year:	60
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:	65
Quantity forecast year:	61
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Complex interventions on the organ system esophagus for adults

Overall result forecast presentation:	yes
Quantity performed reporting year:	27
Quantity forecast year:	24
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:	72
Quantity forecast year:	51
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Stem cell transplant

Overall result forecast presentation:	yes
Quantity performed reporting year:	76
Quantity forecast year:	68
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:	117
Quantity forecast year:	118
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Heart transplant

Overall result forecast presentation:	yes
Quantity performed reporting year:	13
Quantity forecast year:	10
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
CQ02	Quality assurance measures for the inpatient care of children and adolescents with haemato-oncological diseases
CQ03	Quality assurance measures for the implementation of positron emission tomography (PET) in hospitals for the indications non-small-cell lung cancer (NSCLC) and solid pulmonary nodules
CQ24	Quality assurance measures for allogeneic stem cell transplantation for multiple myeloma (valid until 30 June 2022)
CQ25	Measures for quality assurance in the performance of minimally invasive heart valve interventions pursuant to Article 136, para. 1, sentence 1, number 2 for hospitals licensed in accordance with Article 108 of the SGB V
CQ29	Measures for quality assurance of allogeneic stem cell transplantation with in-vitro processing (T-cell depletion via positive enrichment or negative selection) of the transplant in acute lymphoblastic leukaemia (ALL) and acute myeloid leukaemia (AML) in adults

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
462	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*
40	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
40	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

Es liegt eine Dienstanweisung bei V. a. Kindeswohlgefährdung vor, in welcher Handlungsanweisungen hinterlegt sind. Ein (umfassendes) Schutzkonzept ist in Erstellung.

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

Name of the working group: AG Medikamentensicherheit

Training of employees on AMTS related topics

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)

Leitlinie: Umgang mit Arzneimitteln

01.08.2024

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

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

Fallbesprechungen
Echtheitsprüfung aller verifizierungspflichtigen Arzneimittel nach EU-Fälschungsschutzrichtlinie mittels securPharm
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)

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

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

Das UKR bietet für diesen Ausbildungsberuf Praktika in Kooperation mit: - Pschick Group Schulen gGmbH https://www.ukr.de/ausbildung-karriere/ausbildung/physiotherapeuten

HB05 - Medical technical radiology assistant (MTRA) (m/f)

Comment

Das UKR bietet diesen Ausbildungsberuf seit 2019 als duale Ausbildung an. Schule: Eckert Schulen Regenstauf Seit 01.09.2023: Neuordnung "MT-R" https://www.ukr.de/fileadmin/UKR/4-ausbildung-karriere/ausbildung__studium_praktikum/ausbildungsberufe/PE_Steckbrief-MT-R_2025_E1.pdf

HB07 - Surgical technical assistant (m/f)

Comment

Das UKR bietet diesen Ausbildungsberuf als duale Ausbildung an. Schule: San-ak GmbH in München https://www.ukr.de/fileadmin/UKR/4-ausbildung-karriere/ausbildung__studium_praktikum/ausbildungsberufe/PE_Steckbrief-OTA_2025_E2.pdf (bis 2024 besteht noch die Kooperation mit dem IAFW e. V.)

HB09 - Speech therapist (m/f)

Comment

Das UKR bietet diesen Ausbildungsberuf in Kooperation mit: BFS für Logopädie Regensburg Diese ist angegliedert an Abt. f. Phoniatrie und Pädaudiologie der Klinik und Poliklinik f. HNO-Kunde des UKR. https://www.ukr.de/ausbildung-karriere/ausbildung/logopaeden

HB15 - Anaesthesia technical assistant (m/f)

Comment

HB17 - Auxiliary nurse (m/f)

Comment

Das UKR bietet als Träger der Praktischen Ausbildung die Ausbildung zum/zur Generalistischen Pflegefachhelfer/in in Kooperation mit: maxQ. Pflegeschule Regensburg https://www.ukr.de/ausbildung-karriere/ausbildung/pflegefachhelfer

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

Comment

Das UKR bietet für diesen Ausbildungsberuf Praktika in Kooperation mit: - Döpfer Schulen Regensburg GmbH - Malteser Hilfsdienst gemeinnützige GmbH https://www.ukr.de/ausbildung-karriere/ausbildung/notfallsanitaeter

HB19 - Nursing professionals

Comment

Das UKR bietet diesen Ausbildungsberuf als Träger der Praktischen Ausbildung (generalistische Pflegeausbildung) seit 01.04.2020 an. Die Theorie wird am PflegeCampus Regensburg gelehrt. https://www.ukr.de/ausbildung-karriere/ausbildung/pflegefachfrau-/-mann

HB20 - Nursing professional B. Sc.

Comment

In Kooperation mit der OTH Regensburg bietet das UKR seit 10/2020 ein grundständiges Pflegestudium mit Bachelorabschluss an. https://www.ukr.de/ausbildung-karriere/studium-pflege-bsc

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

Comment

Das UKR bietet den neugeordneten Ausbildungsberuf "MT-L" seit 2023 als duale Ausbildung an. Schule: Eckert Schulen Regenstauf https://www.ukr.de/fileadmin/UKR/4-ausbildung-karriere/ausbildung__studium_praktikum/ausbildungsberufe/PE_Steckbrief-MT-L_2025_E1.pdf