Overall result forecast presentation:	yes
Quantity performed reporting year:	55
Quantity forecast year:	51
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
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

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
105	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*
59	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
56	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
  Education
  Note on the measure
  Aufklärung in Leitungsrunden über die G-BA-Anforderung und die Pflicht der Klinik, den Schutz insb. vunerabler Patienten sicherzustellen.
  Age-appropriate complaint options
  Note on the measure
  Die Beschwerdemöglichkeiten sind vielfältig hinsichtlich Meldestelle (telefomisch, per e-Mail, handschriftlich über einen Briefkasten oder die Hauspost) und Ansprechpartner, sodass jeder Melder den für sich (alters-)angemessenen Meldeweg und vertrauensvollen Ansprechpartner selbst wählen kann.
  Training of employees
  Note on the measure
  Schulung und Sensibilisierung von insb. Leitungen zu kritischen Situationen, die im klinischen Umfeld von Mitarbeitenden erlebt, beobachtet oder vermutet wurden sowie zu hilfreichen Dokumenten im Übergriffsfall (Handlungsempfehlungen, Checklisten, Verfahrenanweisungen)
  Information gathering on the topic
  Note on the measure
  Eine Übersicht zu internen und externen Kontaktadressen/Anlaufstellen sowie Entscheidungshilfen, Handlungsempfehlungen, Checklisten und Verfahrensanweisungen wurden im Dokumentenmanagementsystem der Klinik bereitgestellt.
  Code of conduct with rules for treating children and young people with respect
  Note on the measure
  Verhaltenspflichten gegenüber insb. vulnerablen Personengruppen sind in dem Leitbild der Segeberger Kliniken und unseren Führungsgrundsätzen formuliert. Außerdem sind die Verhaltenspflichten aller Mitarbeitenden in der Betriebsordnung der Segeberger Kliniken vertraglich festgehalten.
  
  Last review of the measure
  15.04.2024 19:30:14
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Note on the measure
  Interventionsplan/Checkliste Kindeswohlgefährdung für Berufsgeheimnistragende
  
  Last review of the measure
  21.02.2024 18:30:14
- Review
  Recommendations for dealing with/processing cases that have occurred
  Note on the measure
  Verfahrensanweisung Verhalten bei Übergriffen durch Patienten oder Angehörige
  
  Last review of the measure
  06.03.2019 18:30:14
  Other information on recognition
  Note on the measure
  In 2023 wurde die Verfahrensanweisung aus 2019 umfassend weiterentwickelt zur Prozessbeschreibung Vorgehen bei Verdacht bzw. konkreter Meldung einer Grenzverletzung/-überschreitung, freigegeben 2024-09-06, in der das Vorgehen von Meldung über Ermittlung bis Aufarbeitung umfassend dargestellt ist.

Aufklärung in Leitungsrunden über die G-BA-Anforderung und die Pflicht der Klinik, den Schutz insb. vunerabler Patienten sicherzustellen.

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

Medikamentenmanagement erfolgt digitalisiert über Software (inkl. Arzneimittel-Anamese)

31.12.2024

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)

Praxisleitlinie Richten und Verabreichen von Medikamenten

03.07.2023

SOP on good prescription practices

Handout Orbis Medication- Arzt

29.05.2024

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

Electronic support for the supply of patients with drugs

SavIT (elektronisches Bestellsystem); elektronische Abgabe im KIS

Electronic documentation of the administration of drugs

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)

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
Aushändigung des Medikationsplans
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.