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Klinikum St. Marien Amberg

Klinikum St. Marien Amberg
Klinikum St. Marien Amberg

Mariahilfbergweg 7
92224 Amberg

Phone: 09621-380
Mail: ed.grebma-mukinilk@ofni ed.grebma-mukinilk@ofni ed.grebma-mukinilk@ofni

http://www.klinikum-amberg.de

The St. Marien Hospital in Amberg has 535 beds and covers with its broad medical spectrum all domains of a modern, differentiated tertiary care. We ensure...

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  • Number of beds: 555
  • Number of specialist departments: 22
  • Number of inpatient cases: 26.565
  • Number of partial inpatient cases: 238
  • Number of outpatient cases: 49.437
  • Hospital owners: Stadt Amberg
  • Type of provider: öffentlich
  • Academic teaching hospital
      • LKH der Universität Erlangen-Nürnberg
      • LKH der Universität Regensburg
External comparative quality assurance
Further information
Bezeichnung
Teilnahme externe Qualitätssicherung yes
Koronare Herzkrankheit (KHK)

Quantity performed 147
Exception? No exception
Quantity performed 286
Exception? No exception
Quantity performed 28
Exception? No exception
Quantity performed 12
Exception? No exception
Overall result forecast presentation: yes
Quantity performed reporting year: 147
Quantity forecast year: 159
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: 286
Quantity forecast year: 286
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: 25
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: 12
Quantity forecast year: 20
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
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
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

Full record of compliance maintained

Number of days shown 366
Days of non-performance 0
Number of minimum requirements not met 0
General minimum requirements
Minimum requirement Days of non-performance
Trauma room 0
Availability 0
Computed tomography (CT) 0
Intensive care beds 0
Department of Surgery 0
Forwarding by air 0
Department of Internal Medicine 0
Intensive care beds with ventilator facilities 0
Emergency care training courses 0
Treatment prioritisation system (triage) 0
Responsibility for emergency care 0
Specific minimum requirements
Minimum requirement Days of non-performance
Doctor on duty 0
Supervision by a medical specialist 0
Geriatric expertise 0
Operating room equipment 0
Post-operative physiotherapy 0
Independent organisational unit 0
Minimum requirements for process quality
Minimum requirement Days of non-performance
SOP: Surgical procedures 0
SOP: Perioperative Planning 0
SOP: Capacity to consent 0
Standard Operating Procedure for the Management of Anticoagulants 0
SOP: Ortho-geriatric Care 0
SOP: Physiotherapy Measures 0
SOP: Patient-centred blood management 0
Number Group
203 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*
15 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
14 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.

  • Im Klinikum gibt es eine Kinderschutzgruppe, die sich mit allen Themen dieses Kapitels beschäftigt.
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 commission

Umgang mit Medikamenten

24.07.2024

Umgang mit Medikamenten

24.07.2024

Umgang mit Medikamenten

24.07.2024

  • Bereitstellung einer geeigneten Infrastruktur zur Sicherstellung einer fehlerfreien Zubereitung
  • Zubereitung durch pharmazeutisches Personal
  • Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen
  • 4 Augen Prinzip in Galenik und Zytoherstellung
  • Vorhandensein von elektronischen Systemen zur Entscheidungsunterstützung (z.B. Meona®, Rpdoc®, AIDKlinik®, ID Medics® bzw. ID Diacos® Pharma)
  • Plausibilitätscheck in der Galenik: pharma4u LabXpert; Interaktionsprüfung: UpToDate online, Arzneimittelwechselwirkungen
  • 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)
  • Softwareprogramm Cato im CMR Bereich
  • 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
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.
Job
Explanation

Famulaturen für in D oder im benachb. Ausland (AUT,CZE,HUN) immat. Medizinstudenten; PJ für alle in D immat. Medizinstudenten i.R.v. der PJ-Mobilität über Uni Regensburg u. Uni Erlangen; Einzelfallprüfung für Studenten aus dem Ausland; Ausbildung int. Studenten der Med. Fakultät Karls Uni Pilsen

Explanation

Zahlreiche Phase II Studien zu Tumorerkrankungen; Keine Phase-I-Studien; Studienregister: https://studien.ccc-emn.de/ und https://studien.bzkf.de/

Explanation

Universität Regensburg; Universität des Saarlandes, Universität Duisburg-Essen, Universität Göttingen

Explanation

Diverse Funktionen in Fachgesellschaften; Betr. v. Bachelor-/Masterarbeiten zus. mit OTH/ Medizintechnik Prof. Dr. Bulitta; Koop. mit OTH als innovativer Lernort; Vergabe von Hospitationen und Bachelor-/ Masterarbeiten für den Lehrstuhl Gesundheitsökonomie Universität Bayreuth

Explanation

eigenes Studienzentrum

Explanation

Doktorandenbetreuung in Zusammenarbeit mit Lehruniversitäten

Explanation

Beteiligung an diversen nationalen und internationalen Journale und auch an Lehrbüchern

Explanation

Zahlreiche Phase III/IV Studien zu Tumorerkrankungen; Studienregister: https://studien.ccc-emn.de/ und https://studien.bzkf.de/

Training in other healing professions
Comment

2 Plätze

Comment

24 Plätze

Comment

Kooperation mit der Berufsfachschule Nürnberg

Comment

150 Plätze

Comment

10 Plätze

Comment

Kooperation mit Kliniken Nordoberpfalz; theoretische Ausbildung erfolgt an der Akademie NEWlife in Neustadt a. d. Waldnaab, praktischer Einsatz erfolgt am Klinikum St. Marien Amberg

Comment

2 Plätze (Berufsschule der IAFW in Regensburg - theoretischer Teil, Praxis im Klinikum St. Marien Amberg)

Siegfried Scholz

Patientenfürsprecher

Mariahilfbergweg 7
92224 Amberg

Phone: 09621 -38-1069
Mail: ed.grebma-mukinilk@rehcerpsreufnetneitap

Bettina Rösler-Dolny

Patientenfürsprecherin

Mariahilfbergweg 7
92224 Amberg

Phone: 09621 -38-1069
Mail: ed.grebma-mukinilk@rehcerpsreufnetneitap

Ulrike Lösch

Patientenfürsprecherin

Mariahilfbergweg 7
92224 Amberg

Phone: 09621 -38-1069
Mail: ed.grebma-mukinilk@rehcerpsreufnetneitap

Christine Niebler

Leitung Qualitäts-, Beschwerde- und Projektmanagement

Mariahilfbergweg 7
92224 Amberg

Phone: 09621 -38-4064
Mail: ed.grebma-mukinilk@enitsirhc.relbein

Alisa Rüger

Qualitätsmanagementbeauftragte

Mariahilfbergweg 7
92224 Amberg

Phone: 09621 -38-1161
Mail: ed.grebma-mukinilk@100aregeur

Christina Lang

Qualitätsmanagementbeauftragte

Mariahilfbergweg 7
92224 Amberg

Phone: 09621 -38-1126
Mail: ed.grebma-mukinilk@300cgnal

Christine Niebler

Leitung Qualitäts-, Beschwerde- und Projektmanagement

Mariahilfbergweg 7
92224 Amberg

Phone: 09621 -38-4064
Mail: ed.grebma-mukinilk@enitsirhc.relbein

Christine Nachtmann

Apothekenleiterin & Fachapothekerin für Klinische Pharmazie

Mariahilfbergweg 7
92224 Amberg

Phone: 09621 -38-1096
Mail: ed.grebma-mukinilk@enitsirhc.nnamthcan

Margit Meier

Vorstandsassistentin

Mariahilfbergweg 7
92224 Amberg

Phone: 09621 -38-1202
Mail: ed.grebma-mukinilk@tigram.reiem

Mariahilfbergweg 7
92224 Amberg

Phone: 09621-380
Mail: ed.grebma-mukinilk@ofni

Kerstin Wittmann

Pflegedirektorin

Mariahilfbergweg 7
92224 Amberg

Phone: 09621 -38-1922
Mail: ed.grebma-mukinilk@nitsrek.nnamttiw

Manfred Wendl

Vorstand

Mariahilfbergweg 7
92224 Amberg

Phone: 09621 -38-1200
Mail: ed.grebma-mukinilk@derfnam.ldnew

Dipl.-Verwaltungswirt (FH) Manfred Wendl

Vorstand

Mariahilfbergweg 7
92224 Amberg

Phone: 09621 -38-1200
Mail: ed.grebma-mukinilk@derfnam.ldnew

Dr. med. Harald Hollnberger

Ärztlicher Direktor

Mariahilfbergweg 7
92224 Amberg

Phone: 09621 -38-1910
Mail: ed.grebma-mukinilk@dlarah.regrebnlloh

IK: 260930016

Location number: 772510000

AltersTraumaZentrum

Certified until: 08.2026

Brustkrebszentrum

Certified until: 12.2026

Darmkrebszentrum

Certified until: 12.2026

Dysplasie-Einheit

Certified until: 05.2026

Gynäkologisches Krebszentrum

Certified until: 12.2026

Nierenkrebszentrum

Certified until: 12.2026

Onkologisches Zentrum

Certified until: 12.2026

Pankreaskrebszentrum

Certified until: 12.2026

Prostatakrebszentrum

Certified until: 12.2026

Hospital portrait for download Download quality report