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Immanuel Klinikum Bernau Herzzentrum Brandenburg - Universitätsklinikum der Medizinischen Hochschule Brandenburg Theodor Fontane

Immanuel Klinikum Bernau Herzzentrum Brandenburg - Universitätsklinikum der Medizinischen Hochschule Brandenburg Theodor Fontane
Immanuel Klinikum Bernau Herzzentrum Brandenburg - Universitätsklinikum der Medizinischen Hochschule Brandenburg Theodor Fontane

Ladeburger Straße 17
16321 Bernau

Phone: 03338-6940
Mail: ed.leunammi@uanreb ed.leunammi@uanreb ed.leunammi@uanreb

https://bernau.immanuel.de
  • Number of beds: 290
  • Number of specialist departments: 8
  • Number of inpatient cases: 11.379
  • Number of outpatient cases: 31.298
  • Hospital owners: Krankenhaus Bernau GmbH, eine Gesellschaft der Immanuel Albertinen Diakonie
  • Type of provider: freigemeinnützig
  • University Hospital
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
Quantity performed 17
Exception? No exception
Overall result forecast presentation: yes
Quantity performed reporting year: 17
Quantity forecast year: 20
Examination by state associations? yes
Exemption? yes
Result of the examination by the federal state authorities? yes
Transitional arrangement? no
No. Explanation
CQ07 Measures for quality assurance in the care of pre-term and full-term neonates – perinatal focus
CQ01 Quality assurance measures for inpatient care with the indication abdominal aortic aneurysm
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
CQ31 Guideline for the care of proximal femur fractures (QSFFx-RL)
  • 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

Full record of compliance maintained

Number of days shown 366
Days of non-performance 0
Number of minimum requirements not met 0
General minimum requirements
Minimum requirement Days of non-performance
Trauma room 0
Availability 0
Computed tomography (CT) 0
Intensive care beds 0
Department of Surgery 0
Forwarding by air 0
Department of Internal Medicine 0
Intensive care beds with ventilator facilities 0
Emergency care training courses 0
Treatment prioritisation system (triage) 0
Responsibility for emergency care 0
Specific minimum requirements
Minimum requirement Days of non-performance
Doctor on duty 0
Supervision by a medical specialist 0
Geriatric expertise 0
Operating room equipment 0
Post-operative physiotherapy 0
Independent organisational unit 0
Minimum requirements for process quality
Minimum requirement Days of non-performance
SOP: Surgical procedures 0
SOP: Perioperative Planning 0
SOP: Capacity to consent 0
Standard Operating Procedure for the Management of Anticoagulants 0
SOP: Ortho-geriatric Care 0
SOP: Physiotherapy Measures 0
SOP: Patient-centred blood management 0
Number Group
93 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*
51 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
13 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.

  • Is a protection concept in place? Yes
  • Measures
    • Prevention
    • Intervention
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 commission
  • 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)
  • 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
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.
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Training in other healing professions
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Praktikumsplätze

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Start der Ausbildung jeweils am 1. April und 1. Oktober eines jeden Jahres

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Start der Ausbildung 1. April eines jeden Jahres

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Ausbildungsstart am 1. April eines jeden Jahres

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Praktikumsplätze

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Start der Ausbildung am 01. Oktober eines jeden Jahres

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Praktikumsplätze

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Lutz Haertel

Patientenfürsprecher

Ladeburger Straße 17
16321 Bernau

Phone: 03338 -694440-
Mail: ed.leunammi@rehcerpsreufnetneitap.uanreb

Daniela Zacharias

Leitung Qualitätsmanagement

Ladeburger Straße 17
16321 Bernau

Phone: 03338 -694925-
Mail: ed.nenitreblaleunammi@sairahcaz.aleinad

Daniela Zacharias

Leitung Qualitätsmanagement

Ladeburger Straße 17
16321 Bernau

Phone: 03338 -694925-
Mail: ed.nenitreblaleunammi@sairahcaz.aleinad

Dr. med. Georg Fritz

Chefarzt der Abteilung Anästhesie, Intensivmedizin und Schmerztherapie, Vorsitzender der Arzneimittelkommission

Ladeburger Straße 17
16321 Bernau

Phone: 03338 -694110-
Mail: ed.nenitreblaleunammi@ztirf.groeg

Ivonne Pukall

Leitung Patientenmanagement

Ladeburger Straße 17
16321 Bernau

Phone: 03338 -694440-
Mail: ed.nenitreblaleunammi@llakup.ennovi

Ladeburger Straße 17
16321 Bernau

Phone: 03338-6940
Mail: ed.leunammi@uanreb

Dipl. KS Birgit Pilz

Pflegedirektorin

Ladeburger Straße 17
16321 Bernau

Phone: 03338 -694900-
Mail: ed.nenitreblaleunammi@zlip.tigrib

Verena Plocher

Geschäftsführerin

Ladeburger Straße 17
16321 Bernau

Phone: 03338 -694910-
Mail: ed.nenitreblaleunammi@rehcolp.anerev

Andreas Mende

Geschäftsführer ab 01.10.2025

Ladeburger Straße 17
16321 Bernau

Phone: 030 -80505272-
Mail: ed.nenitreblaleunammi@ednem.saerdna

Matthias Scheller

Geschäftsführer

Ladeburger Straße 17
16321 Bernau

Phone: 030 -80505272-
Mail: ed.leunammi@liam

Verena Plocher

Geschäftsführerin

Ladeburger Straße 17
16321 Bernau

Phone: 03338 -694910-
Mail: ed.nenitreblaleunammi@rehcolp.anerev

Univ.-Professor Dr. med. Johannes Albes

Chefarzt Herzchirurgie

Ladeburger Straße 17
16321 Bernau

Phone: 03338 -694510-
Mail: ed.nenitreblaleunammi@sebla.sennahoj

Univ.-Professor Dr. med. Christian Butter

Chefarzt Kardiologie

Ladeburger Straße 17
16321 Bernau

Phone: 03338 -694610-
Mail: ed.nenitreblaleunammi@rettub.naitsirhc

Dr. med. Michael Zänker

Chefarzt Innere Medizin

Ladeburger Straße 17
16321 Bernau

Phone: 03338 -694410-
Mail: ed.nenitreblaleunammi@rekneaz.leahcim

IK: 261200311

Location number: 773116000

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