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Krankenhaus Ludmillenstift

Krankenhaus Ludmillenstift
Krankenhaus Ludmillenstift
  • Number of beds: 420
  • Number of specialist departments: 15
  • Number of inpatient cases: 18.285
  • Number of partial inpatient cases: 39
  • Number of outpatient cases: 76.000
  • Hospital owners: Kuratorium der Stiftung Ludmillenstift
  • Type of provider: freigemeinnützig
  • Academic teaching hospital
      • Carl-von-Ossietzky Universität Oldenburg
Further information
  • External quality assurance according to state law
    No participation
Quantity performed 76
Exception? No exception
Quantity performed 8
Exception? No exception
Das Krankenhaus war zur Erbringung der mindestmengenrelevanten Leistung berechtigt, weil die Landesverbände der Krankenkassen und die Ersatzkassen die Prognose des Krankenhauses für das Berichtsjahr bestätigt hatten. Die Mindestmenge wurde im Berichtsjahr jedoch entgegen der mengenmäßigen Erwartung nicht erreicht. (MM08)
Quantity performed 11
Exception? No exception
Das Krankenhaus war zur Erbringung der mindestmengenrelevanten Leistung berechtigt, weil die Landesverbände der Krankenkassen und die Ersatzkassen die Prognose des Krankenhauses für das Berichtsjahr bestätigt hatten. Die Mindestmenge wurde im Berichtsjahr jedoch entgegen der mengenmäßigen Erwartung nicht erreicht. (MM08)
Quantity performed 164
Exception? No exception
Overall result forecast presentation: yes
Quantity performed reporting year: 76
Quantity forecast year: 76
Examination by state associations? yes
Exemption? yes
Result of the examination by the federal state authorities? yes
Transitional arrangement? no
Overall result forecast presentation: no
Quantity performed reporting year: 8
Quantity forecast year: 11
Examination by state associations? no
Exemption? no
Result of the examination by the federal state authorities? no
Transitional arrangement? no
Overall result forecast presentation: no
Quantity performed reporting year: 11
Quantity forecast year: 14
Examination by state associations? no
Exemption? no
Result of the examination by the federal state authorities? no
Transitional arrangement? no
Overall result forecast presentation: yes
Quantity performed reporting year: 164
Quantity forecast year: 139
Examination by state associations? yes
Exemption? yes
Result of the examination by the federal state authorities? yes
Transitional arrangement? no
No. Explanation
CQ05 Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 1
CQ31 Guideline for the care of proximal femur fractures (QSFFx-RL)
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
  • Clarifying chat completed: no
  • Clarifying chat not completed: no
  • No participation in clarifying chat: no
  • Notification of non-fulfilment of nursing care not made: yes

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
112 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*
71 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
71 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.

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

Z. B. bundeseinheitlicher Medikationsplan, Stammblatt oder Software in der Notaufnahme.

28.05.2021

AW Medikamentenverabreichung [21529]

16.02.2021

  • Bereitstellung einer geeigneten Infrastruktur zur Sicherstellung einer fehlerfreien Zubereitung
  • Zubereitung durch pharmazeutisches Personal
  • Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen
  • Vorhandensein von elektronischen Systemen zur Entscheidungsunterstützung (z.B. Meona®, Rpdoc®, AIDKlinik®, ID Medics® bzw. ID Diacos® Pharma)
  • 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)
  • Electronisch unterstütztes System zur eindeutigen Beschriftung/Etikettieruntg zubereiteter intravenösier Medikamente (PRAXIKETT® Designer)
  • 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
  • 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.
Job
Explanation

Frau Dr. Veer Dozentin , Campus Papenburg

Explanation

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Training in other healing professions
Comment

Comment

In Kooperation mit Niels Stensen Bildungszentrum (Osnabrück).

Comment

Hebammenwissenschaft B.sc. in Kooperation mit der Jade Hochschuke Oldenburg

Comment

In Kooperation mit NSK Bildungsinstitut Osnabrück.

Comment

In Kooperation mit Niels Stensen Bildungszentrum (Osnabrück).

Comment

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In Kooperation mit der Hochschule Osnabrück Campus Lingen

Gisela Meyer

Patientenfürsprecherin

Ludmillenstraße 4-6
49716 Meppen

Phone: 05931 -152-1093
Mail: ed.tfitsnellimdul@rehcerpsreufnetneitap

Kathmann Iris

Qualitätsmanagment

Ludmillenstraße 4-6
49716 Meppen

Phone: 05931 -152-1048
Mail: ed.tfitsnellimdul@mq

Kramer Vildana

Qualitätsmanagement

Ludmillenstraße 4-6
49716 Meppen

Phone: 05931 -152-1048
Mail: ed.tfitsnellimdul@mq

Lohe Franziska

Qualitätsmanagement

Ludmillenstraße 4-6
49716 Meppen

Phone: 05931 -152-1048
Mail: ed.tfitsnellimdul@mq

Andreas Fierdag

Qualitätsmanagementbeauftragter

Ludmillenstraße 4-6
49716 Meppen

Phone: 05931 -152-1042
Mail: ed.tfitsnellimdul@gadreif

Jan Schmitz

Leitender Apotheker

Ludmillenstraße 4-6
49716 Meppen

Phone: 05931 -152-1900
Mail: ed.tfitsnellimdul@ztimhcs.j

Phillipp Herbers

Ansprechpartner für Menschen mit Behinderungen

Ludmillenstraße 4-6
49716 Meppen

Phone: 05931 -152-0
Mail: ed.tfitsnellimdul@srebreh

Heike Burrichter

Pflegedirektorin

Ludmillenstraße 4-6
49716 Meppen

Phone: 05931 -152-1040
Mail: ed.tfitsnellimdul@rethcirrub

Bis zum 22.11.2024 Jan-Henning Stoffers

Geschäftsführender Verwaltungsdirektor

Ludmillenstraße 4-6
49716 Meppen

Phone: 05931 -152-1000
Mail: ed.tfitsnellimdul@sreffots

Ab dem 22.11.2024 Stefan Lammers

Geschäftsführender Verwaltungsdirektor

Ludmillenstraße 4-6
49716 Meppen

Phone: 05931 -152-1006
Mail: ed.tfitsnellimdul@sremmal

Herr Lutz Blume

Geschäftsführender Verwaltungsdirektor

Ludmillenstraße 4-6
49716 Meppen

Phone: 05931 -152-1000
Mail: ed.tfitsnellimdul@emulb.ztul

Dr. med. Mario Konen

Ärztlicher Direktor

Ludmillenstraße 4-6
49716 Meppen

Phone: 05931 -152-6026
Mail: ed.tfitsnellimdul@nenok

IK: 260340615

Location number: 773405000

Überregionales Traumazentrum im Traumanetzwerk Nord-West

Certified until: 09.2023

EndoProthetikZentrum Ludmillenstift Meppen

EndoProthetikZentrum Ludmillenstift Meppen

Certified until: 02.2024

Überregionale Stroke Unit

Certified until: 01.2023

Nachsorgeeinrichtung für Frühgeborene, schwerstkranke und schwerstbehinderte Kinder "Bunter Kreis Emsland am Ludmillenstift"

Certified until: 06.2024

Frauenklinik am Ludmillenstift mit Emsländischem Brustzentrum und Gynäkologischem Brustzentrum (DIN EN ISO 9001:2015)

Certified until: 09.2023

Chest Pain Unit (DKG zertifiziert)

Certified until: 02.2023

Kinder - und Jugendmedizin (Ausgezeichnet für Kinder)

Certified until: 12.2023

Medizinische Frührehabilitation und Altersmedizin (DEGEMED, DIN EN ISO 9001:2015)

Certified until: 03.2025

Pathologie und Zytologie (DIN EN ISO 9001:2015)

Certified until: 06.2023

EndoProthetikZentrum

Certified until: 02.2027