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Niels-Stensen-Kliniken Marienhospital Osnabrück

Bischofsstraße 1
49074 Osnabrück

Phone: 0541-326-0
Mail: ed.ksn@ohm-noitamrofni ed.ksn@ohm-noitamrofni ed.ksn@ohm-noitamrofni

https://www.niels-stensen-kliniken.de/mho

Basic information

Number of beds: 630
Number of specialist departments: 14

Number of inpatient cases: 32.938
Number of outpatient cases: 79.931

Hospital owners: Marienhospital Osnabrück GmbH (mit den Gesellschaftern Niels-Stensen-Kliniken GmbH und Bischöflicher Stuhl zu Osnabrück)
Type of provider: freigemeinnützig

Academic teaching hospital

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

Participation in other external comparative quality assurance procedures

Implementation of the minimum quantity agreement

Treatment area

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

Quantity performed	36
Exception?	No exception

Complex operations on the pancreatic organ system

Quantity performed	56
Exception?	No exception

Complex interventions on the organ system esophagus for adults

Quantity performed	27
Exception?	No exception

Minimum quantities forecast

Complex operations on the pancreatic organ system

Overall result forecast presentation:	yes
Quantity performed reporting year:	56
Quantity forecast year:	37
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:	27
Quantity forecast year:	24
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

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

Overall result forecast presentation:	yes
Quantity performed reporting year:	36
Quantity forecast year:	38
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
CQ05	Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 1
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
CQ01	Quality assurance measures for inpatient care with the indication abdominal aortic aneurysm
CQ31	Guideline for the care of proximal femur fractures (QSFFx-RL)

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
175	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*
117	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
113	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
  Education
  Note on the measure
  Enge Zusammenarbeit mit dem Christlichen Kinderhospital Osnabrück in direkter Gebäudeanbindung. Infomaterial z.B. Leitfaden Kinderschutz, Leitfaden Probeweis, SOP Opferschutz, besonders in der ZNA
  Training of employees
  Note on the measure
  Enge Zusammenarbeit mit dem Christlichen Kinderhospital Osnabrück in direkter Gebäudeanbindung. Pflichtunterweisung "Prävention sexualisierter Gewalt" (online)
  Information gathering on the topic
  Note on the measure
  Enge Zusammenarbeit mit dem Christlichen Kinderhospital Osnabrück in direkter Gebäudeanbindung. Veröffentlichung von Informationsmaterial wie z.B. "Leitfaden ProBeweis"
  Code of conduct with rules for treating children and young people with respect
  Note on the measure
  Alle Mitarbeitenden müssen eine Selbstverpflichtungserklärung abgeben.
  
  Last review of the measure
  29.12.2021 19:52:35
  Special requirements for the selection of persons
  Note on the measure
  Alle Mitarbeitenden müssen eine entsprechende Straffreiheitserklärung abgeben.

Enge Zusammenarbeit mit dem Christlichen Kinderhospital Osnabrück in direkter Gebäudeanbindung. Infomaterial z.B. Leitfaden Kinderschutz, Leitfaden Probeweis, SOP Opferschutz, besonders in der ZNA

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

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

Verfahrensanweisung Arzneimitteltherapiesicherheit

14.03.2024

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 Arzneimitteltherapiesicherheit; Empfehlungen zum Richten und Stellen von Tabletten

14.03.2024

SOP on good prescription practices

Verfahrensanweisung Arzneimitteltherapiesicherheit; Verfahrensanweisung Umgang mit Betäubungsmitteln

14.03.2024

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

Electronic support for the supply of patients with drugs

Bei Bestellung, Herstellung und Abgabe von Arzneimitteln werden eingesetzt: Orbis Medication, MMI Pharmaindex, AMeLI, MobiDik, Zenzy, Dr. Lennartz Laborprogramm

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)
Umsetzung 4-Augen-Prinzip, Einsatz von Stationsapotheker*innen inklusive Begehungen der Stationen, Risikoaudits im Bereich AMTS, Erstellung von Verfahrensanweisungen zur AMTS, Verwendung von DIVI-Spritzenaufkleber, getrennte Aufbewahrung von „Look alike“ und „Sound alike“- Arzneimitteln

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
Ärztliches und pflegerisches Entlassungsgespräch; Verfahrensanweisung zur Verordnung von Betäubungsmitteln im Rahmen des Entlassungsmanagements

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

Mehrere Kliniken / Chefarztbereiche.

FL09 - Doctoral supervision

Explanation

In mehreren Bereichen zu unterschiedlichsten Themen.

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

Insb. Chefärzte als Professoren oder Privat-Dozenten an Universitäten.

FL08 - Editors of scientific journals/textbooks

Explanation

Klinik für Augenheilkunde

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

Lehraufträge zu verschiedenen Themen.

FL04 - Project-related cooperation with colleges and universities

Explanation

Kooperation mit mehreren Universitäten und Hochschulen.

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

Explanation

Mehrere Kliniken / Chefarztbereiche.

FL03 - Student training (clinical traineeship / internship year)

Explanation

Das Marienhospital Osnabrück ist akademisches Lehrkrankenhaus der Medizinischen Hochschule Hannover.

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

Explanation

Mehrere Kliniken / Chefarztbereiche.

Training

Training in other healing professions

HB07 - Surgical technical assistant (m/f)

Comment

In Kooperation mit dem Niels Stensen Bildungszentrum

HB17 - Auxiliary nurse (m/f)

Comment

Genauer: Pflegeassistent(inn)en. In Kooperation mit den Berufsbildenden Schulen Marienheim Sutthausen und dem Niels Stensen Bildungszentrum.

HB10 - Midwife (m/f)

Comment

In Kooperation mit der Akademie St. Franziskus in Lingen und der Akademie des Klinikums Osnabrück

HB03 - Physical therapist / physiotherapist (m/f)

Comment

Angebot von Praktika im Rahmen der Ausbildung

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

Comment

Neue Bezeichnung: Pflegefachmann/-frau (s.u.): in Kooperation mit dem Niels Stensen Bildungszentrum

HB15 - Anaesthesia technical assistant (m/f)

Comment

In Kooperation mit dem Niels Stensen Bildungszentrum

HB05 - Medical technical radiology assistant (MTRA) (m/f)

Comment

Neue Bezeichnung: Medizinische/-r Technologe/-in für Radiologie: Ausbildung in Kooperation mit dem Niels Stensen Bildungszentrum

HB12 - Medical technical laboratory assistant (MTLA) (m/f)

Comment

Praktika im Rahmen der beim Klinikum Osnabrück angesiedelten schulischen Ausbildung.

HB02 - Health and paediatric nurse (m/f)

Comment

Neue Bezeichnung: Pflegefachmann/-frau mit Vertiefung Pädiatrie: am Niels Stensen Bildungszentrum in Kooperation mit dem Christlichen Kinderhospital Osnabrück in direkter räumlicher Anbindung an das Marienhospital Osnabrück.

HB20 - Nursing professional B. Sc.

Comment

Duales Studium angebunden an Niels Stensen Bildungszentrum

HB18 - Emergency paramedics (m/f) (training period 3 years)

Comment

Kooperation mit zwei Berufsfachschulen

HB19 - Nursing professionals

Comment

In Kooperation mit dem Niels Stensen Bildungszentrum

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 20
- Additional staff: 27
- Explanations: Das Marienhospital Osnabrück gehört dem Verbund der Niels-Stensen-Kliniken mit einer Zentralapotheke an. Die dort tätigen Apotheker und Apothekerinnen sowie weiteres pharmazeutisches Personal sind auch für unsere Einrichtung tätig.
- Nursing staff regulation