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Klinikum Mutterhaus der Borromäerinnen gGmbH Standort Mitte/Nord

Feldstraße 16
54290 Trier

Phone: 0651-9470
Mail: ed.suahrettum@ofni ed.suahrettum@ofni ed.suahrettum@ofni

http://www.mutterhaus.de/

Basic information

Number of beds: 1.077
Number of specialist departments: 24

Number of inpatient cases: 34.333
Number of partial inpatient cases: 1.225
Number of outpatient cases: 69.598

Hospital owners: Klinikum Mutterhaus der Borromäerinnen gGmbH
Type of provider: freigemeinnützig

Academic teaching hospital

Specialist departments

Services

Quality

External comparative quality assurance

Further information

External quality assurance according to state law

Bezeichnung
Teilnahme externe Qualitätssicherung	yes

External quality assurance according to the DMP

Diabetes mellitus Typ 2

Implementation of the minimum quantity agreement

Treatment area

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

Quantity performed	25
Exception?	No exception

Knee joint total endoprostheses

Quantity performed	291
Exception?	No exception

Complex interventions on the organ system esophagus for adults

Quantity performed	28
Exception?	No exception

Complex operations on the pancreatic organ system

Quantity performed	27
Exception?	No exception

Minimum quantities forecast

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

Overall result forecast presentation:	yes
Quantity performed reporting year:	25
Quantity forecast year:	30
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:	291
Quantity forecast year:	294
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:	28
Quantity forecast year:	23
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:	27
Quantity forecast year:	37
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Surgical treatment of breast cancer (mamma surgery)

Overall result forecast presentation:	yes
Quantity performed reporting year:	431
Quantity forecast year:	418
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
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
CQ05	Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 1

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: yes

Further training
pursuant to Article 136b, para. 1, sentence 1, no. 1 of the SGB

Number	Group
228	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*
38	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
15	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
  
  Training of employees
  
  Education
  Code of conduct with rules for treating children and young people with respect
  Last review of the measure
  01.07.2022 21:04:56
  Age-appropriate complaint options
  Note on the measure
  Ausgewiesene Ombudpersonen
  Kinderschutzbund intern/extern
  Kooperation mit Jugendamt und weiteren Einrichtungen
  Special requirements for the selection of persons
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Last review of the measure
  01.06.2022 21:04:56
- Review
  Other information on recognition
  Note on the measure
  Erstkontakt mit Dienstvorgesetzten, Diplompsychologen oder qualifizierten Ombudspersonen, externen unabhängigen Ansprechpersonen (Juristen), Empfehlungen zu professionellen Unterstützungsmöglichkeiten, Hilfsangebote potentielle Täter: "kein Täter werden", Arbeitsplatzgestaltung in Zukunft. Die Individualität der Fälle zieht eine individuelle Aufarbeitung nach sich, die aber standardisiert innerhalb der Ombudgruppe und weiteren Personen / Vorgesetzten besprochen und geplant wird

Ausgewiesene Ombudpersonen Kinderschutzbund intern/extern Kooperation mit Jugendamt und weiteren Einrichtungen

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: AMTS-Team

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

Empfehlungen der Apotheke zur Weiterführung der Medikation

01.02.2023

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)

relevante Dokumentation im digitalen Dokumentenmanagement

01.12.2024

SOP on good prescription practices

relevante Dokumentation im digitalen Dokumentenmanagement

01.12.2024

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
Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen
Herstellung aller onkologischen Zubereitungen in der Apotheke, Herstellung von Standardspritzen für die Intensivstation in der Apotheke, Herstellung von Ernährungslösungen und Wirkstoffzubereitungen f

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)
Versorgung der Patientinnen und Patienten mit patientenindividuell abgepackten Arzneimitteln durch die Krankenhausapotheke (z.B. Unit-Dose-System)
Medikation in M-KIS. ICM. CGMMuse: elektronische Bestellung. WinZenzy: elektronische Bestellung Chemotherapie und TPN. Übermittlung der Daten zur Chemotherapie aus WinZenzy nach M-KIS Rowa: Abgabe vo

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)
Therapiemonitoring onkologische und neonatologische Patienten. Kurvenvisiten der Stationsapotheker. Visiten der Stationsapotheker vor Ort. Eingabe der Aufnahmemedikation in M-KIS durch Stationsapothek
Therapiemonitoring onkologische und neonatologische Patienten

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.

Special instrument-based equipment

Research & teaching

Job

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

Seit 10/20 Koop.partner des Medizincampus Trier (MCT) der Universitätsmedizin Mainz, Vorlesung und Studierendenbetreuung entspr. dem Vorlesungsplan. Zus. Promotionsbetreuung und Teilnahme an multiplen Studien. Alle Habilitierte und APL Professoren haben einen Lehrauftrag an ihren Heimatuniversitäten

FL03 - Student training (clinical traineeship / internship year)

Explanation

In allen Fachbereichen werden Famulaturen für Medizinstudierende angeboten. Das Klinikum ist seit 1977 Akademisches Lehrkrankenhaus der Universitätsmedizin Mainz Regelmäßige Ausbildung, und M3 Prüfung von PJ Studierenden des SS und WS der UM und anderer Fakultäten.

FL04 - Project-related cooperation with colleges and universities

Explanation

Duales Studium Betriebswirtschaftslehre (BWL) mit Schwerpunkt Gesundheitsmanagement Hochschule Mannheim, Dualer Studiengang Klinische Pflege Universität Trier, Dualer Studiengang Bachelor of Science „Gesundheit und Pflege“ Fachhochschule Mainz, Medizininformatik und Medizintechnik Hochschule Trier

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