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St.-Clemens-Hospital Geldern

Clemensstraße 6
47608 Geldern

Phone: 02831-390
Fax: 02831-390-3000
Mail: ed.latipsoh-snemelc@gnutlawrev

http://www.clemens-hospital.de

Basic information

Number of beds: 305
Number of specialist departments: 13

Number of inpatient cases: 12.582
Number of partial inpatient cases: 307
Number of outpatient cases: 24.951

Hospital owners: cusanus trägergesellschaft trier mbH
Type of provider: freigemeinnützig

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

Implementation of the minimum quantity agreement
No participation

Implementation of resolutions of the Federal Joint Committee on quality assurance (G-BA)

No.	Explanation
CQ07	Measures for quality assurance in the care of pre-term and full-term neonates – perinatal focus
CQ28	Guideline on quality assurance measures for liposuction procedures for stage III lipedema (QS-RL Liposuction)

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
78	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*
58	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
58	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
  Other aspects of prevention
  Note on the measure
  Ein Schutzkonzept des Trägers liegt vor. Jährliche Schulungen erfolgen.

Ein Schutzkonzept des Trägers liegt vor. Jährliche Schulungen erfolgen.

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

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

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)

2.0.1.03. Risikomanagement

01.08.2023

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®)

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)
Sonstige_elektronische_Unterstuetzung

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)

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

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

FL03 - Student training (clinical traineeship / internship year)

Explanation

In medizinischen Fachbereichen besteht die Möglichkeit der Durchführung einer Famulatur.

FL09 - Doctoral supervision

Explanation

PD Dr. med. Andreas Fußhöller / Universität Düsseldorf

FL04 - Project-related cooperation with colleges and universities

Explanation

PD Dr. med. Andreas Fußhöller / Universität Düsseldorf

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

PD Dr. med. Andreas Fußhöller / Universität Düsseldorf

Training

Training in other healing professions

HB07 - Surgical technical assistant (m/f)

Comment

Beginn der Ausbildung alle drei Jahre am 1. Oktober. Kooperierende Schule: Therese-Valerius-Akademie für Gesundheitsberufe Duisburg e.V.

HB02 - Health and paediatric nurse (m/f)

Comment

Beginn der Ausbildung am 1. Oktober - Kooperierende Schule: Schule für Pflegeberufe Sana Kliniken Duisburg

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

Comment

Beginn der Ausbildung am 1. April und 1. September des laufenden Jahres. Kooperierende Schule: Kath. Bildungsakademie Niederrhein

HB17 - Auxiliary nurse (m/f)

Comment

Beginn der Ausbildung am 1. April und 1. September des laufenden Jahres. Kooperierende Schule: Kath. Bildungsakademie Niederrhein

HB19 - Nursing professionals

Comment

Beginn der Ausbildung am 1. April und 1. September des laufenden Jahres. Kooperierende Schule: Kath. Bildungsakademie Niederrhein

HB10 - Midwife (m/f)

Comment

Studienform: Duales Studium. Beginn zum 1. September eines Jahres in Zusammenarbeit mit der Hochschule Niederrhein in Krefeld. Beginn zum 1.Oktober eines Jahres in Zusammenarbeit mit der Fliedner Fachhochschule Düsseldorf.

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 1
- Explanations: Ein Vertrag mit einer externen Apotheke regelt die Verfügbarkeit einer Apothekerin in unserem Haus. Die Apothekerin und ggf. weitere Apotheker sind mehrmals wöchentlich im Krankenhaus, sind Ansprechpartner in allen Fragen zu Arzneimitteln und prüfen regelmäßig die Arzneimitteltherapiesicherheit.
- Nursing staff regulation