Overall result forecast presentation:	yes
Quantity performed reporting year:	430
Quantity forecast year:	453
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
CQ31	Guideline for the care of proximal femur fractures (QSFFx-RL)

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
72	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*
15	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
14	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
  
  Information gathering on the topic
  
  Education
  Code of conduct with rules for treating children and young people with respect
  Last review of the measure
  18.10.2024 19:18:11
  Age-appropriate complaint options
  
  Special requirements for the selection of persons
  
  Training of employees
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Note on the measure
  Verfahrensanweisung bei Übergriffen und strafrechtlich relevanten Handlungen im Haupt- und Ehrenamt
  
  Last review of the measure
  07.05.2024 19:18:11
  Other aspects of intervention
- Review
  Recommendations for dealing with/processing cases that have occurred
  Note on the measure
  Richtlinie Prävention und Intervention sexualisierter Gewalt im Malteser Verbund
  
  Last review of the measure
  07.05.2024 19:18:11
  Other information on recognition

Verfahrensanweisung bei Übergriffen und strafrechtlich relevanten Handlungen im Haupt- und Ehrenamt

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

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

Anamnesebogen

01.12.2021

SOP on good prescription practices

SOP Verordnungen und Bescheinigungen im Rahmen des EM

23.02.2023

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®)

Measures to minimise medication errors

Fallbesprechungen
Maßnahmen zur Vermeidung von Arzneimittelverwechslung
Teilnahme an einem einrichtungsübergreifenden Fehlermeldesystem (siehe Kapitel 12.2.3.2)

Measures to ensure seamless drug therapy after discharge

bei Bedarf Arzneimittel-Mitgabe oder Ausstellung von Entlassrezepten
Aushändigung von arzneimittelbezogenen Informationen für die Weiterbehandlung und Anschlussversorgung der Patientin oder des Patienten im Rahmen eines (ggf. vorläufigen) Entlassbriefs

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

FL03 - Student training (clinical traineeship / internship year)

Explanation

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

Explanation

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

FL04 - Project-related cooperation with colleges and universities

Explanation

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

Explanation

FL09 - Doctoral supervision

Explanation

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

Explanation

FL08 - Editors of scientific journals/textbooks

Explanation

Training

Training in other healing professions

HB07 - Surgical technical assistant (m/f)

Comment

https://www.waldkrankenhaus.de/karriere/ausbildung/operationstechnische-assistentin.html https://www.waldkrankenhaus.de/ausbildungen.html

HB19 - Nursing professionals

Comment

https://www.pflegeausbildung-erlangen.de/ https://www.waldkrankenhaus.de/ausbildungen.html

HB17 - Auxiliary nurse (m/f)

Comment

https://www.waldkrankenhaus.de/ausbildungen.html https://www.pflegeausbildung-erlangen.de/

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 1
- Additional staff: 3
- Explanations: Über Kooperation
- Nursing staff regulation

Service contact persons

Patient advocates

Dr. med. Horst Beyer

Patientenfürsprecher

Rathsberger Straße 57
91054 Erlangen

Phone: 09131 -822-0
Mail: ed.suahneknarkdlaw@rehcerpsreufnetneitap

Customer feedback management

Michael Rettner

Leitung Qualitätsmanagement & klinisches Risikomanagement

Rathsberger Straße 57
91054 Erlangen

Phone: 09131 -822-3973
Mail: ed.suahneknarkdlaw@tnemeganamedrewhcseb

Dr. med. Carsten Haeckel

Geschäftsführer

Rathsberger Straße 57
91054 Erlangen

Phone: 09131 -822-3973
Mail: ed.suahneknarkdlaw@tnemeganamedrewhcseb

Hannes Petersen

Mitarbeiter Qualitätsmanagement

Rathsberger Straße 57
91054 Erlangen

Phone: 09131 -822-3973
Mail: ed.suahneknarkdlaw@tnemeganamedrewhcseb

Quality management

Michael Rettner

Leitung Qualitätsmanagement & klinisches Risikomanagement

Rathsberger Straße 57
91054 Erlangen

Phone: 09131 -822-3468
Mail: ed.suahneknarkdlaw@rentter.leahcim

Responsible for drug therapy

Dr. med. Horst Huber

Ärztlicher Direktor / Chefarzt

Rathsberger Straße 57
91054 Erlangen

Phone: 09131 -822-3268
Mail: ed.suahneknarkdlaw@rebuh.tsroh

Accessibility Officer

Sabine Siebenhaar

Leitung Patientenmanagement

Rathsberger Straße 57
91054 Erlangen

Phone: 09131 -822-3259
Mail: ed.suahneknarkdlaw@gnutlawrevnetneitap

Company

General contact details of the hospital

Rathsberger Straße 57
91054 Erlangen

Phone: 09131-822-0
Mail: ed.suahneknarkdlaw@ofni

Nursing service management

Thomas Paule

Pflegedirektor

Rathsberger Straße 57
91054 Erlangen

Phone: 09131 -822-3246
Mail: ed.suahneknarkdlaw@eluap.samoht

Sandra Kok-Kaiser

Stellv. Pflegedirektorin

Rathsberger Straße 57
91054 Erlangen

Phone: 09131 -822-3246
Mail: ed.suahneknarkdlaw@resiak-kok.ardnas

Head of administration

Dr. med. Carsten Haeckel

Geschäftsführer

Rathsberger Straße 57
91054 Erlangen

Phone: 09131 -822-3249
Mail: ed.suahneknarkdlaw@lekceah.netsrac

Andreas Garlt

Kaufmännischer Direktor

Rathsberger Straße 57
91054 Erlangen

Phone: 09131 -822-3636
Mail: ed.suahneknarkdlaw@tlrag.saerdna

Responsible for the quality report in the hospital management

Dr. med. Carsten Haeckel

Geschäftsführer

Rathsberger Straße 57
91054 Erlangen

Phone: 09131 -822-3249
Mail: ed.suahneknarkdlaw@lekceah.netsrac

Medical management

Dr. med. Horst Huber

Ärztlicher Direktor / Chefarzt der Klinik für Anästhesie und Intensivmedizin

Rathsberger Straße 57
91054 Erlangen

Phone: 09131 -822-3268
Mail: ed.suahneknarkdlaw@rebuh.tsroh

IK number

IK: 260950066

Location number

Location number: 771393000

EndoProthetikZentrum der Maximalversorgung am Malteser Waldkrankenhaus St. Marien - EPZ Erlangen

Certified until: 03.2026

Geriatrie-Zentrum Erlangen

Certified until: 04.2026

Chest Pain Unit der Medizinischen Klinik I im Malteser Waldkrankenhaus St. Marien

Certified until: 07.2025

Certificates

Chest Pain Unit

Certified until: 07.2030

Hernienchirurgie

Certified until: 08.2027

Nierenkrebszentrum

Certified until: 06.2027

Onkologisches Zentrum

Certified until: 06.2027

Prostatakrebszentrum

Certified until: 06.2027

Hospital portrait for download