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Dietrich-Bonhoeffer-Klinikum Standort Neubrandenburg

Salvador-Allende-Straße 30
17036 Neubrandenburg

Phone: 0395-775-0
Fax: 0395-775-192009
Mail: ed.bnkbd@ofni

http://www.dbknb.de

Basic information

Number of beds: 851
Number of specialist departments: 29

Number of inpatient cases: 28.392
Number of partial inpatient cases: 2.447
Number of outpatient cases: 43.909

Hospital owners: Diakonie Klinikum Dietrich Bonhoeffer GmbH
Type of provider: freigemeinnützig

Specialist departments

Services

Quality

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

Implementation of the minimum quantity agreement

Treatment area

Complex interventions on the organ system esophagus for adults

Quantity performed	17
Exception?	No exception

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

Quantity performed	9
Exception?	No exception

Knee joint total endoprostheses

Quantity performed	3
Exception?	No exception

Complex operations on the pancreatic organ system

Quantity performed	48
Exception?	No exception

Minimum quantities forecast

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

Overall result forecast presentation:	no
Quantity performed reporting year:	9
Quantity forecast year:	8
Examination by state associations?	no
Exemption?	no
Result of the examination by the federal state authorities?	no
Transitional arrangement?	no

Complex interventions on the organ system esophagus for adults

Overall result forecast presentation:	no
Quantity performed reporting year:	17
Quantity forecast year:	26
Examination by state associations?	no
Exemption?	no
Result of the examination by the federal state authorities?	no
Transitional arrangement?	no

Complex operations on the pancreatic organ system

Overall result forecast presentation:	yes
Quantity performed reporting year:	48
Quantity forecast year:	55
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:	no
Quantity performed reporting year:	3
Quantity forecast year:	4
Examination by state associations?	no
Exemption?	no
Result of the examination by the federal state authorities?	no
Transitional arrangement?	no

Implementation of resolutions of the Federal Joint Committee on quality assurance (G-BA)

No.	Explanation
CQ05	Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 1
CQ01	Quality assurance measures for inpatient care with the indication abdominal aortic aneurysm

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
135	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*
95	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
95	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
  Note on the measure
  Kinderschutzgruppe akkreditiert durch die Gesellschaft für Kinderschutz in der Medizin (DGKiM) mit der Internetseite https://dbknb.de/kch/kinderschutzgruppe; Vemittlung von Kontakten zum Jugendamt zur Familienhilfe
  Training of employees
  Note on the measure
  Zertifikat Kinderschutzmediziner; Teilnahme an der DGKiM-Jahrestagung; Fachtagung Kinderkrankenpflege mit dem Fokus "Kindeswohlgefährdung"; Fachvorvorträge für die Ausbildung von Pädiatrischen Intensiv- und Anästhesiepflegekräften
  Code of conduct with rules for treating children and young people with respect
  Note on the measure
  Grundsatzerklärung und Verhaltenskodex für Mitarbeitende
  
  Last review of the measure
  02.12.2022 16:32:08
  Education
  Note on the measure
  Mitarbeitende im DBK, niedergelassene Ärzte, Mitarbeiter in Kindereinrichtungen, beim
  Rettungsdienst oder in Schulen; fallbezogene Hilfsangebote u. Aufklärung
  Special requirements for the selection of persons
  Note on the measure
  erweitertes Führungszeugnis
  Age-appropriate complaint options
  Note on the measure
  für interne und externe Beschwerden besteht ein zentrales Beschwerde- und Meldeverfahren sowie direkte Beschwerdemöglichkeiten bei Mitarbeitenden
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Note on the measure
  Verdacht Kindeswohlgefährdung (DA-00754) und Verdacht sexueller Missbrauch - Untersuchungsablauf und Vorgehen (DA-00755)
  
  Last review of the measure
  27.05.2022 17:32:08
  Other aspects of intervention
  Note on the measure
  Erfassungs-/Untersuchungsbögen zur Diagnostik bei Verdacht auf Gefährdung von Kindeswohl u. Kindergesundheit; Fallkonferenzen; Mitteilungsbögen an das bzw. Meldung durch das Jugendamt bei Kindeswohlgefährdung; Begleit-/Übergabedokumentation KPI bzw. Rechtsmedizin
- Review
  Other information on recognition
  Note on the measure
  Aufarbeitung u. Superversion mit Mitarbeitenden; fallbezogene Auswertung in der Kinderschutzgruppe

Verdacht Kindeswohlgefährdung (DA-00754) und Verdacht sexueller Missbrauch - Untersuchungsablauf und Vorgehen (DA-00755)

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

DA-00087 "Arbeitsordnung zum Umgang mit Arzneimitteln und Medicalprodukten"; VA-00086 "Bestellung und Belieferung der Kliniken; Medikationsplan; Optiplan Anordnungsbogen und Patientenkurve

17.01.2022

Process description for an optimal medication process (e.g. drug anamnesis – prescription – patient information – drug delivery – drug application – documentation – therapy monitoring – result evaluation)

DA-00087 "Arbeitsordnung zum Umgang mit Arzneimitteln und Medicalprodukten; ST-00126 "Antibiotikaleitlinie"; VA-00086 Apotheke - Bestellung und Belieferung der Kliniken; ST-00967 "Orale Medikamente richten"; ST-00473 "Verabreichen von Medikamenten über PEG-Sonde"

17.01.2022

SOP on good prescription practices

ST-00126 "Antibiotikaleitlinie" 6. Auflage 2020

17.09.2020

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
Zentrale Krankenhausapotheke; DA-00087 "Umgang mit Arzneimitteln und Medicalprodukten"; ST-00967 "Orale Medikamente richten"; DA-00085 "Umgang mit Zytostatika"; ST-00128 "Antibiotikaleitlinie"

Measures to minimise medication errors

Fallbesprechungen
Maßnahmen zur Vermeidung von Arzneimittelverwechslung
DA-00087 "Umgang mit Arzneimitteln und Medicalprodukten"; DA-00147 "Chargensperrung und Rückrufe"; Meldeformulare unerwünschte Arzneimittelwirkungen; einrichtungsinternes CIRS; Stationsbegehungen nach § 14 ApoG und § 32 ApBetrO; Visiten zur klinischen Ernährung

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