Overall result forecast presentation:	yes
Quantity performed reporting year:	119
Quantity forecast year:	144
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:	21
Quantity forecast year:	14
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
CQ06	Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 2

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
149	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*
100	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
100	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
  
  Training of employees
  
  Education
  Code of conduct with rules for treating children and young people with respect
  Last review of the measure
  03.01.2022 16:46:43
  Age-appropriate complaint options
  
  Special requirements for the selection of persons
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Last review of the measure
  26.01.2023 16:46:43

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

Use of standardised forms for drug medical history

Unit-Dose-Verfahren (Baxter)

16.10.2019

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)

SOP on good prescription practices

QM/RM-Dokumentation

21.03.2022

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)
Versorgung der Patientinnen und Patienten mit patientenindividuell abgepackten Arzneimitteln durch die Krankenhausapotheke (z.B. Unit-Dose-System)

Measures to minimise medication errors

Fallbesprechungen
Maßnahmen zur Vermeidung von Arzneimittelverwechslung
einrichtungsinterne Fehlermeldesystem (CIRS)
Vermeidung von Arzneimittelverwechslungen (Sound-a-like, Look-a-like)
Fallanfragen an die Apotheker (Therapieoptimierung)

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
bei Bedarf Arzneimittel-Mitgabe oder Ausstellung von Entlassrezepten
Aushändigung des Medikationsplans

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

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

Lehrbeauftragungen an der Friedrich-Schiller-Uni Jena und Eberhard-Karl-Uni Tübingen Dozenturen: Friedrich-Schiller-Universität Jena Universität Leipzig Martin-Luther-Universität Halle-Wittenberg Hochschule für Musik Weimar und Außenstelle Weißenfels der Hochschule St. Elizabeth Bratislava

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

Lehrbeauftragung an Fachhochschule Jena: "Ernst-Abbe" Lehrbeauftragungen an evangelischer Krankenpflegeschule im Klinikum Weimar

FL03 - Student training (clinical traineeship / internship year)

Explanation

Das Sophien- und Hufeland-Klinikum ist ein akademisches Lehrkrankenhaus. In dieser Verantwortung bieten wir Medizinstudenten die Möglichkeit, ihr praktisches Jahr in den Kliniken bzw. Bereichen unseres Hauses zu absolvieren. Die PJ-Studenten erhalten am Weimarer Klinikum eine Praktikumsvergütung.

FL04 - Project-related cooperation with colleges and universities

Explanation

Friedrich-Schiller-Universität Jena, Technische Universität Ilmenau, Hochschule Bratislava, Fachhochschule Jena, Institut für Mikrobiologie der FSU Jena, Eberhard-Karl-Universität Thübingen, Teilnahme am "QUIPS"-Projekt (Schmerztherapie) sowie an Schmerzstudie "LOPSTER" der FSU Jena

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

Explanation

Teilnahme an Studie zur Pränavigation beim Kniegelenkersatz Teilnahme an Studie zur stationären Behandlung der Epistaxis (Nasenblutung)

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

Explanation

Teilnahme an: PROOF multizentrische Studie unter Leitung Charite Berlin zu periprothetischen Gelenkinfektionen Teilnahme an multizentrischen Schmerzstudie Phase III Grünenthal (MS-Studie, Schlaganfall) Teilnahme am Projekt RESET-CRT (Herzinsuffizienz-Patienten)

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

Explanation

Teilnahme an PEONS-Studie der FSU Jena Ganganalysesysteme, BAP-Arbeitsplatz-Forschung (in Koop.: FH Jena, TU Ilmenau)

FL08 - Editors of scientific journals/textbooks

Explanation

Mitherausgeber/Section Editor: "Journal of Physical and Rehabilitation Medicine", "Musikphysiologie" & "Manuelle Medizin" Lehrbuch „Funktionelle & beschreibende Anatomie d. Menschen“ & „Grundwissen Rehabilitation, Physik.Therapie, Naturheilverfahren“ Konsenskonferenz Physikal. & Rehabilit. Medizin

Training

Training in other healing professions

HB03 - Physical therapist / physiotherapist (m/f)

Comment

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

Comment

Als Kooperationspartner zweier medizinischer Fachschulen in Erfurt und Jena ("Berufsbildende Schule für Gesundheit und Soziales") übernimmt die Klinik für Radiologie und Nuklearmedizin den praktischen Teil der Ausbildung zum/zur MTRA.

HB06 - Occupational therapist (m/f)

Comment

HB07 - Surgical technical assistant (m/f)

Comment

Operationstechnische Assistenten der "Berufsbildende Schule für Gesundheit und Soziales" in Weimar finden während ihrer Praktika Einsatz im Zentral-OP, auf den chirugischen Pflegestationen, im Notfallzentrum und in der Sterilgutversorgungsabteilung.

HB19 - Nursing professionals

Comment

Das Weimarer Klinikum verfügt über eine eigene evangelische Pflegeschule mit 200 Plätzen für die Ausbildung zur Pflegefachfrau und Pflegefachmann. Im Jahr 2022 wurden nach dreijähriger Ausbildungszeit 14 Auszubildende durch das Klinikum übernommen.