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LMU Klinikum München - Campus Großhadern

LMU Klinikum München - Campus Großhadern
LMU Klinikum München - Campus Großhadern

Marchioninistraße 15
81377 München

Phone: 089-44000
Mail: ed.nehcneum-inu.mukinilk@ofni ed.nehcneum-inu.mukinilk@ofni ed.nehcneum-inu.mukinilk@ofni

https://www.lmu-klinikum.de/
  • Number of beds: 1.164
  • Number of specialist departments: 31
  • Number of inpatient cases: 46.653
  • Number of partial inpatient cases: 6.189
  • Number of outpatient cases: 269.073
  • Hospital owners: Freistaat Bayern
  • Type of provider: öffentlich
  • University Hospital
External comparative quality assurance
Further information
Bezeichnung
Teilnahme externe Qualitätssicherung yes
Rheumatoide Arthritis

Quantity performed 73
Exception? No exception
Quantity performed 89
Exception? No exception
Quantity performed 75
Exception? No exception
Quantity performed 142
Exception? No exception
Quantity performed 60
Exception? No exception
Quantity performed 114
Exception? No exception
Quantity performed 39
Exception? No exception
Quantity performed 543
Exception? No exception
Quantity performed 84
Exception? No exception
Overall result forecast presentation: yes
Quantity performed reporting year: 73
Quantity forecast year: 80
Examination by state associations? yes
Exemption? yes
Result of the examination by the federal state authorities? yes
Transitional arrangement? no
Overall result forecast presentation: yes
Quantity performed reporting year: 89
Quantity forecast year: 98
Examination by state associations? yes
Exemption? yes
Result of the examination by the federal state authorities? yes
Transitional arrangement? no
Overall result forecast presentation: yes
Quantity performed reporting year: 75
Quantity forecast year: 77
Examination by state associations? yes
Exemption? yes
Result of the examination by the federal state authorities? yes
Transitional arrangement? no
Overall result forecast presentation: yes
Quantity performed reporting year: 142
Quantity forecast year: 152
Examination by state associations? yes
Exemption? yes
Result of the examination by the federal state authorities? yes
Transitional arrangement? no
Overall result forecast presentation: yes
Quantity performed reporting year: 60
Quantity forecast year: 44
Examination by state associations? yes
Exemption? yes
Result of the examination by the federal state authorities? yes
Transitional arrangement? no
Overall result forecast presentation: yes
Quantity performed reporting year: 114
Quantity forecast year: 114
Examination by state associations? yes
Exemption? yes
Result of the examination by the federal state authorities? yes
Transitional arrangement? no
Overall result forecast presentation: yes
Quantity performed reporting year: 39
Quantity forecast year: 31
Examination by state associations? yes
Exemption? yes
Result of the examination by the federal state authorities? yes
Transitional arrangement? no
Overall result forecast presentation: yes
Quantity performed reporting year: 543
Quantity forecast year: 533
Examination by state associations? yes
Exemption? yes
Result of the examination by the federal state authorities? yes
Transitional arrangement? no
Overall result forecast presentation: yes
Quantity performed reporting year: 84
Quantity forecast year: 82
Examination by state associations? yes
Exemption? yes
Result of the examination by the federal state authorities? yes
Transitional arrangement? no
Overall result forecast presentation: yes
Quantity performed reporting year: 28
Quantity forecast year: 35
Examination by state associations? yes
Exemption? yes
Result of the examination by the federal state authorities? yes
Transitional arrangement? no
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
CQ08 Measures for quality assurance of cardiac surgery care in children and adolescents according to Article 136, para. 1, sentence 1, no. 2 of the SGB V
CQ24 Quality assurance measures for allogeneic stem cell transplantation for multiple myeloma (valid until 30 June 2022)
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
CQ26 Decision on measures for quality assurance of targeted lung denervation by catheter ablation in chronic obstructive pulmonary disease
CQ27 Guideline on quality assurance measures for inpatient care with bronchoscopic lung volume reduction procedures for severe emphysema (QS Guideline bronchoscopic LVR /QS-RL BLVR)
CQ29 Measures for quality assurance of allogeneic stem cell transplantation with in-vitro processing (T-cell depletion via positive enrichment or negative selection) of the transplant in acute lymphoblastic leukaemia (ALL) and acute myeloid leukaemia (AML) in adults
CQ31 Guideline for the care of proximal femur fractures (QSFFx-RL)
  • 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
quarter Q1
Erwachsenenpsychiatrie
Day shift
Compliance with minimum requirements yes
Level of implementation 92,0 %
Occupational group Minimum requirements met Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten ja 100,69 %
Pflegefachpersonen nein 90,22 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen ja 96,13 %
Spezialtherapeutinnen und Spezialtherapeuten nein 89,9 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten ja 96,8 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen ja 104,04 %
quarter Q2
Erwachsenenpsychiatrie
Day shift
Compliance with minimum requirements yes
Level of implementation 97,0 %
Occupational group Minimum requirements met Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten ja 109,9 %
Pflegefachpersonen ja 96,04 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen ja 95,88 %
Spezialtherapeutinnen und Spezialtherapeuten nein 91,37 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten nein 93,55 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen ja 96,34 %
quarter Q3
Erwachsenenpsychiatrie
Day shift
Compliance with minimum requirements no
Level of implementation 95,0 %
Occupational group Minimum requirements met Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten ja 102,75 %
Pflegefachpersonen ja 94,02 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen ja 90,67 %
Spezialtherapeutinnen und Spezialtherapeuten ja 92,93 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten ja 100,81 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen ja 97,9 %
quarter Q4
Erwachsenenpsychiatrie
Day shift
Compliance with minimum requirements no
Level of implementation 99,0 %
Occupational group Minimum requirements met Level of implementation (%)
Ärztinnen und Ärzte, ärztliche Psychotherapeutinnen und Psychotherapeuten ja 110,77 %
Pflegefachpersonen ja 98,65 %
Psychotherapeutinnen und Psychotherapeuten (ohne ärztliche Psychotherapeutinnen und Psychotherapeuten), Psychologinnen und Psychologen ja 92,8 %
Spezialtherapeutinnen und Spezialtherapeuten ja 92,1 %
Bewegungstherapeutinnen und Bewegungstherapeuten, Physiotherapeutinnen und Physiotherapeuten ja 99,17 %
Sozialarbeiterinnen und Sozialarbeiter, Sozialpädagoginnen und Sozialpädagogen, Heilpädagoginnen und Heilpädagogen ja 92,59 %
Number Group
622 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*
45 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
44 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.
  • Name of the working group: AMIKUM - AMTS-Arbeitsgruppe des Klinikums; Arzneimittelkommission; zentrales QM

Prozessbeschreibungen/Strategie: CIRS - Critical Incident Reporting System (19.09.2022); Risikomanagement (07.09.2023); Morbiditäts- u. Mortalitätskonferenzen (17.09.2022); Strategie Risikomanagement (27.11.2023)

07.09.2023

Medikationsprozess

05.07.2021

  • Bereitstellung einer geeigneten Infrastruktur zur Sicherstellung einer fehlerfreien Zubereitung
  • Zubereitung durch pharmazeutisches Personal
  • Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen
  • Arzneimittelbezogene Information der Apotheke zur korrekten Zubereitung von Parenteralia
  • 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)
  • SRM (Bestellung), zenzy (Herstellung)
  • 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)
  • Pharmazeutische Arzneimittelanamnese, qualitätsgesicherte Arzneimittelinformation aus der Apotheke, Qualitätszirkel "Sicherheit bei der Chemotherapieanforderung", Interaktionschecks durch die Apotheke
  • 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
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.
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Training in other healing professions
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Auf dieser Seite finden Sie das gesamte Ausbildungsangebot des LMU Klinikum: https://lmu-klinikum.de/karriere/berufsausbildung/cbbf1e93d430a264

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https://www.bszg.lmu-klinikum.de/bfs-krankenpflegehilfe

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In Kooperation mit der Schwesternschaft vom BRK e.V.

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Die Hebammenausbildung ist seit dem WS2021/2022 vollständig akademisiert und läuft als Ausbildung in Heilberufen aus.

Dieter Muck

Patientenführsprecher

Marchioninistraße 15
81377 München

Phone: 0152 -54889802-
Mail: ed.nehcneum-inu.dem@nretxe.kcum.reteid

Thomas Lange

Leitender Beschwerdemanager der Stabsstelle Zentrales Beschwerdemanagement Ärztliche Direktion

Marchioninistraße 15
81377 München

Phone: 089 -4400-72128
Mail: ed.nehcneum-inu.dem@egnaL.T

Dr. med. Wolfgang Piehlmeier

Leiter der Stabsstelle Qualitäts- und Risikomanagement des Vorstands

Marchioninistraße 15
81377 München

Phone: 089 -4400-58088
Mail: ed.nehcneum-inu.dem@reiemlheip.gnagflow

Monika Andraschko

GF AMK und Leitung Apotheke

Marchioninistraße 15
81377 München

Phone: 089 -4400-73600
Mail: ed.nehcneum-inu.dem@okhcsardna.akinom

Diana Gigacher

Patientenempfang

Marchioninistraße 15
81377 München

Phone: 089 -4400-72111
Mail: ed.nehcneum-inu.dem@rehcagiG.anaiD

Marchioninistraße 15
81377 München

Phone: 089-44000
Mail: ed.nehcneum-inu.mukinilk@ofni

Carolin Werner

Pflegedirektorin seit 01.10.2023, Mitglied des Vorstands

Marchioninistraße 15
81377 München

Phone: 089 -4400-72120
Mail: ed.nehcneum-inu.dem@noitkeridegelfp

Markus Zendler

Kaufmännischer Direktor, Mitglied des Vorstands

Marchioninistraße 15
81377 München

Phone: 089 -4400-72001
Mail: ed.nehcneum-inu.dem@reldnez.sukram

Prof. Dr. med. Markus Lerch

Ärztlicher Direktor; Vorsitzender des Vorstands

Marchioninistraße 15
81377 München

Phone: 089 -4400-72101
Mail: ed.nehcneum-inu.dem@dea

Prof. Dr. med. Markus M. Lerch

Ärztlicher Direktor und Vorstandsvorsitzender

Marchioninistraße 15
81377 München

Phone: 089 -4400-72101
Mail: ed.nehcneum-inu.dem@dea

IK: 260914050

Location number: 771736000

Chirurgische Koloproktologie

Certified until: 04.2027

Cochlea-Implantat versorgende Einrichtung

Certified until: 06.2026

Palliativdienste im Krankenhaus

Certified until: 04.2027

Palliativstation

Certified until: 12.2027

Stroke Unit

Certified until: 06.2026

Zentrum für Personalisierte Medizin

Certified until: 03.2027

Hospital portrait for download