Overall result forecast presentation:	yes
Quantity performed reporting year:	19
Quantity forecast year:	24
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:	22
Quantity forecast year:	33
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
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
204	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*
31	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
27	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
  Zusammenarbeit mit der Kinderschutzmedizinischen Ambulanz der Darmstädter Kinderkliniken Prinzessin Margaret (https://kinderkliniken.de/leistungen/kinderschutz/); Kontaktdaten der Medizinischen Kinderschutzhotline (interne Veröffentlichung und Aushang von Plakaten)
  Special requirements for the selection of persons
  Note on the measure
  "Führungszeugnis für private Zwecke" zur Vorlage bei Einstellung
  Code of conduct with rules for treating children and young people with respect
  Note on the measure
  Dienstanweisung Kommunikationskodex
  
  Last review of the measure
  21.08.2023 16:37:30
  Education
  Note on the measure
  Deeskalationstrainings, PME Familienservice und der Einsatz von Arbeitspsycholog*innen für MItarbeitende
  Age-appropriate complaint options
  Note on the measure
  Das Lob- und Beschwerdebüro steht allen Beschwerdeführer*innen, unabhängig der Altersgruppe, zur Verfügung (https://klinikum-darmstadt.de/patienten-besucherinnen/lob-kritik).
  Training of employees
  Note on the measure
  Deeskalationstrainings
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Note on the measure
  SOP Medizinische Soforthilfe nach Vergewaltigung
  
  Last review of the measure
  24.11.2022 15:37:30
  Other aspects of intervention
  Note on the measure
  Zusammenarbeit mit der Kinderschutzmedizinischen Ambulanz der Darmstädter Kinderkliniken Prinzessin Margaret (https://kinderkliniken.de/leistungen/kinderschutz/).
- Review
  Recommendations for dealing with/processing cases that have occurred
  Note on the measure
  Eine Handlungsempfehlung zur Aufarbeitung aufgetretener Fälle liegt vor.
  
  Last review of the measure
  07.07.2023 16:37:30

Zusammenarbeit mit der Kinderschutzmedizinischen Ambulanz der Darmstädter Kinderkliniken Prinzessin Margaret (https://kinderkliniken.de/leistungen/kinderschutz/); Kontaktdaten der Medizinischen Kinderschutzhotline (interne Veröffentlichung und Aushang von Plakaten)

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

Formular Arzneimittelanamnese

25.08.2022

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)

Dienstanweisung Arzneimittel und Dienstanweisung Umgang mit Betäubungsmitteln

17.10.2022

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
Eigenherstellung im Herstellungsbereich sowie Zystostatikalabor nach geltenden Vorschriften. Bestellungen von gebrauchsfertigen Arzneimitteln sind immer möglich.

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)
Die Hausliste steht in Form des e-Shops zur Verfügung Umstellungen erfolgen mittels Austauschtabelle oder automatisiert im elektronischen System.

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 des Medikationsplans
bei Bedarf Arzneimittel-Mitgabe oder Ausstellung von Entlassrezepten
Der Medikationsplan wird aus der elektronischen Patientenkurve erstellt. Die Mitgabe von Arzneimitteln und die Ausstellung von Entlassrezepten ist in der VA Entlassmanagement geregelt.

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

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

Explanation

FL08 - Editors of scientific journals/textbooks

Explanation

FL03 - Student training (clinical traineeship / internship year)

Explanation

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

Explanation

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

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

Explanation

FL04 - Project-related cooperation with colleges and universities

Explanation

FL09 - Doctoral supervision

Explanation

Training

Training in other healing professions

HB01 - Nurse and health care worker (m/f)

Comment

Praktische Ausbildung am KDA, theoretische Ausbildung am BZG

HB10 - Midwife (m/f)

Comment

in Kooperation (seit Mitte 2020 ein duales Studium)

HB20 - Nursing professional B. Sc.

Comment

Praktische Ausbildung am KDA, theoretische Ausbildung am BZG und DHBW (auslaufend)/ ab WS 2022 mit der Katholischen Hochschule Mainz

HB19 - Nursing professionals

Comment

Praktische Ausbildung am KDA, theoretische Ausbildung am BZG

HB17 - Auxiliary nurse (m/f)

Comment

Praktische Ausbildung am KDA, theoretische Ausbildung am BZG

HB07 - Surgical technical assistant (m/f)

Comment

in Kooperation

HB15 - Anaesthesia technical assistant (m/f)

Comment

in Kooperation

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 9
- Additional staff: 10
- Nursing staff regulation

Service contact persons

Patient advocates

Petra Diefenbach

Patientenfürsprecherin

Grafenstraße 9
64283 Darmstadt

Phone: 06151 -107-944642
Mail: ed.tdatsmrad-mukinilk.liam@ofni

Vera Freund

Patientenfürsprecherin

Grafenstraße 9
64283 Darmstadt

Phone: 06151 -107-944642
Mail: ed.tdatsmrad-mukinilk.liam@ofni

Customer feedback management

Katharina Abich

Lob- und Beschwerdebüro

Grafenstraße 9
64283 Darmstadt

Phone: 06151 -107-4666
Mail: ed.tdatsmrad-mukinilk.liam@gnuniemeniem

Judith Haida-Langendorf

Lob- und Beschwerdebüro

Grafenstraße 9
64283 Darmstadt

Phone: 06151 -107-4666
Mail: ed.tdatsmrad-mukinilk.liam@gnuniemeniem

Katharina Abich

Lob- und Beschwerdebüro

Grafenstraße 9
64283 Darmstadt

Phone: 06151 -107-4666
Mail: ed.tdatsmrad-mukinilk.liam@gnuniemeniem

Quality management

Nicole Fritsch

Bereichsleitung Qualitätsmanagement/Risikomanagement

Grafenstraße 9
64283 Darmstadt

Phone: 06151 -107-5092
Mail: ed.tdatsmrad-mukinilk.liam@hcstirf.elocin

Hygiene officer

Dr. med. Jörg Noetzel

Medizinischer Geschäftsführer

Grafenstraße 9
64283 Darmstadt

Phone: 06151 -107-5001
Mail: ed.tdatsmrad-mukinilk.liam@gnurheufstfeahcseg

Dr. med. Jörg Noetzel

Medizinischer Geschäftsführer

Grafenstraße 9
64283 Darmstadt

Phone: 06151 -107-5001
Mail: ed.tdatsmrad-mukinilk.liam@gnurheufstfeahcseg

Responsible for drug therapy

Bettina Mayer

Apothekerin

Grafenstraße 9
64283 Darmstadt

Phone: 06151 -107-5605
Mail: ed.tdatsmrad-mukinilk.liam@reyam.anitteb

Accessibility Officer

Marion Rodehau

Hausdame

Grafenstraße 9
64283 Darmstadt

Phone: 06151 -107-5080
Mail: ed.tdatsmrad-mukinilk.liam@uahedoR.noiraM

Company

General contact details of the hospital

Grafenstraße 9
64283 Darmstadt

Phone: 06151-107-0
Fax: 06151-107-5009
Mail: ed.tdatsmrad-mukinilk.liam@ofni

Nursing service management

Michele Tarquinio Espadas

Pflegerischer Geschäftsführer

Grafenstraße 9
64283 Darmstadt

Phone: 06151 -107-5701
Mail: ed.tdatsmrad-mukinilk.liam@noitkeridegelfp

Head of administration

Clemens Maurer

Kaufmännischer Geschäftsführer

Grafenstraße 9
64283 Darmstadt

Phone: 06151 -107-5001
Mail: ed.tdatsmrad-mukinilk.liam@gnurheufstfeahcseg

Responsible for the quality report in the hospital management

Clemens Maurer

Geschäftsführer

Grafenstraße 9
64283 Darmstadt

Phone: 06151 -107-5002
Mail: ed.tdatsmrad-mukinilk.liam@gnurheufstfeahcseg

Medical management

Dr. med. Jörg Noetzel

Medizinischer Geschäftsführer seit 01.06.2023

Grafenstraße 9
64283 Darmstadt

Phone: 06151 -107-5001
Mail: ed.tdatsmrad-mukinilk.liam@gnurheufstfeahcseg

Prof. Dr. med. Nawid Khaladj

Medizinischer Geschäftsführer bis 31.12.2022

Grafenstraße 9
64283 Darmstadt

Phone: 06151 -107-5001
Mail: ed.tdatsmrad-mukinilk.liam@gnurheufstfeahcseg

Dr. med. Jörg Noetzel

Medizinischer Geschäftsführer seit 01.06.2023

Grafenstraße 9
64283 Darmstadt

Phone: 06151 -107-5001
Mail: ed.tdatsmrad-mukinilk.liam@gnurheufstfeahcseg

Regional care obligation for psychiatry?

IK number

IK: 260610019

Location number

Location number: 771807000

Old location number: 771807000

Certified centers

Überregionale Stroke Unit

Certified until: 04.2024

Überregionales Traumazentrum

Certified until: 04.2025

Schwerstverletzungsartenverfahren (SAV)

Certified until: 01.2025

Onkologisches Zentrum (DKG)

Certified until: 03.2023

Brustkrebszentrum (DKG)

Certified until: 03.2025

Darmkrebszentrum (DKG)

Certified until: 03.2023

Viszeralonkologisches Zentrum (DKG)

Certified until: 03.2023

Gynäkologisches Krebszentrum (DKG)

Certified until: 03.2025

Hautkrebszentrum (DKG)

Certified until: 03.2025

Magenkrebszentrum (DKG)

Certified until: 03.2023

Pankreaskrebszentrum (DKG)

Certified until: 03.2023

Chest Pain Unit (DGK)

Certified until: 06.2024

Shunt-Referenzzentrum

Certified until: 06.2025

Nephrologische Schwerpunktklinik

Certified until: 09.2024

Zentrum für Hypertonie (DGFN/DHL®)

Certified until: 09.2024

Cardiac Arrest Center

Certified until: 03.2025

Hospital portrait for download