Sana Klinikum Lichtenberg

Fanningerstraße 32
10365 Berlin

Phone: 030-5518-0
Fax: 030-5558-4004
Mail: ed.anas@noitamrofni.lks

https://www.sana.de/berlin

• Tagesklinik für Manuelle Medizin • Klinik für Allgemein- und Viszeralchirurgie • Klinik für Anästhesiologie und Intensivmedizin • Klinik für Frauenheilkunde...

Basic information

Number of beds: 672
Number of specialist departments: 16

Number of inpatient cases: 28.524
Number of partial inpatient cases: 1.335
Number of outpatient cases: 37.359

Hospital owners: Sana Kliniken Berlin-Brandenburg GmbH
Type of provider: privat

Specialist departments

Services

Quality

External comparative quality assurance

Further information

External quality assurance according to state law
No participation

External quality assurance according to the DMP

Koronare Herzkrankheit (KHK)

Implementation of the minimum quantity agreement

Treatment area

Complex operations on the pancreatic organ system

Quantity performed	77
Exception?	No exception

Knee joint total endoprostheses

Quantity performed	156
Exception?	No exception

Complex interventions on the organ system esophagus for adults

Quantity performed	33
Exception?	No exception

Minimum quantities forecast

Complex operations on the pancreatic organ system

Overall result forecast presentation:	yes
Quantity performed reporting year:	77
Quantity forecast year:	72
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:	156
Quantity forecast year:	150
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:	602
Quantity forecast year:	608
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:	33
Quantity forecast year:	43
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
CQ06	Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 2
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: yes

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

Number	Group
161	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*
121	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
80	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
No care for children and young people

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

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)

Verfahrensanweisung Anwendung von Arzneimitteln

15.06.2022

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

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)

Measures to minimise medication errors

Fallbesprechungen
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
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

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

Explanation

Leitung als Hauptprüfer der Studienzentren - Initiierung weniger - Phase III- und IV-Studien

FL03 - Student training (clinical traineeship / internship year)

Explanation

KL als Akademisches Lehrkrankenhaus der Charité - Universitätsmedizin Berlin, Betreuung von PJ-Studenten und Famulanten

FL08 - Editors of scientific journals/textbooks

Explanation

Publikationen in Fachliteratur und Referenz-Standardwerken, Originalarbeiten und Review-Artikel, z.T. Herausgeber eigener Bücher (z.B. Editor EJPE, Co-Editor PIDJ, Viszeralchirurgie, Urologie etc.), Mitautoren in Buchwerken z.B. Kompendium Intensivmedizin

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

z.B. Alice Salomon Hochschule Berlin, Hochschule für Wirtschaft und Recht

FL04 - Project-related cooperation with colleges and universities

Explanation

z.B. Charité, Universität Greifswald insb. auf dem Gebiet der Radiologie, Medizinische Hochschule Brandenburg

FL09 - Doctoral supervision

Explanation

erfolgt vielfältig; auch in Verbindung mit Studien

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

z.B. Evangelische Hochschule Berlin (Hebammen), Universitätsmedizin Mannheim

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

Explanation

Phase III-Studien - mit Arzneimitteln vor der Zulassung, Phase IV-Studien - mit Arzneimitteln oder Medizinprodukten nach der Zulassung

Training

Training in other healing professions

HB06 - Occupational therapist (m/f)

Comment

Kooperationsvertrag über die Vereinbarung zur Durchführung der praktischen Ausbildung in der Ergotherapie mit der Akademie der Gesundheit Berlin/Brandenburg e.V. und der Wannseeschule, Medizinische Akademie am UKB

HB03 - Physical therapist / physiotherapist (m/f)

Comment

Vertrag zur ergänzenden praktischen Ausbildung zum staatlich anerkannten Physiotherapeuten mit der Akademie der Gesundheit Berlin/Brandenburg e.V., SOWI Strausberg und Medizinische Akademie am UKB, Schule für Physiotherapie

HB19 - Nursing professionals

Comment

Koop. m. Akademie der Gesundheit Bln/Brbg e.V. für theor. Ausbildg.; Koop. über prakt. Ausbildg. mit Verb. Lichtenberger Seniorenheime, KEH, Domino World, Park-Klinik-Weißensee, Park Vital GmbH Pfl. zu Hause, HU-MA Pfl. GmbH, Domicil Sen.pfl.heim GmbH u. versch. Hauskrankenpflegeeinrichtungen

HB09 - Speech therapist (m/f)

Comment

Kooperationsvertrag über die praktische Ausbildung zum Logopäden mit der Medizinischen Akademie am UKB; Akademie der Gesundheit Berlin/Brandenburg e.V.

HB07 - Surgical technical assistant (m/f)

Comment

Kooperationsvertrag über die praktische Ausbildung mit Sana Sterilgut Service GmbH, Akademie der Gesundheit Berlin/Brandenburg e.V.

HB16 - Dietician (m/f)

Comment

Vereinbarung über die praktische Ausbildung von Diätassistenten/innen mit Charité Gesundheitsakademie

HB21 - Geriatric nurse (m/f)

Comment

Koop. prakt. Ausbildg. mit Verbund Lichtenberger Sen.-Heime, KEH, Domino World, HU-MA Pfl. GmbH, Domicil Seniorenpfl.-Heim GmbH; Häusl. Krankenpfl. Irmtraud Reichel GmbH; Spreevital Häusl. Pflegedienst GmbH; Hauskrankenpfl. Stolley GmbH; Zentrum f. Beatmung u. Intensivpfl. im “Storkower Bogen” GmbH

HB02 - Health and paediatric nurse (m/f)

Comment

Akademie d. Gesundheit Berlin/Brandenburg e.V. theor. Ausbildg., prakt. Ausbildg.: Verbund Lbg. Sen.-Heime, KEH, Domino World, HU-MA Pflege, Domicil Sen.-Pflegeheim GmbH Spreevital Häusl.Pflegedienst GmbH; Hauskrankenpfl.Stolley GmbH; Zentrum f.Beatmung u. Intensivpfl. im “Storkower Bogen”GmbH

HB17 - Auxiliary nurse (m/f)

Comment

Kooperation zur Durchführung der praktischen Ausbildung für Krankenpflegehelfer/Innen mit der Akademie der Gesundheit Berlin/Brandenburg e.V.

HB10 - Midwife (m/f)

Comment

Kooperation mit der Akademie der Gesundheit Berlin/Brandenburg e.V. Campus Eberswalde für die theoretische Ausbildung

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 3
- Additional staff: 8
- Explanations: Die Apotheke des Sana Klinikums Lichtenberg versorgt die Sana Kliniken Sommerfeld, das Sana Krankenhaus Templin und das Sana Klinikum Lichtenberg mit Arzneimitteln. Eine personelle Zuordnung des Personals zu den Klinikstandorten wird nicht getroffen.
- Nursing staff regulation