Overall result forecast presentation:	yes
Quantity performed reporting year:	9
Quantity forecast year:	12
Examination by state associations?	yes
Exemption?	no
Result of the examination by the federal state authorities?	no
Transitional arrangement?	no

Complex operations on the pancreatic organ system

Overall result forecast presentation:	yes
Quantity performed reporting year:	14
Quantity forecast year:	16
Examination by state associations?	yes
Exemption?	no
Result of the examination by the federal state authorities?	no
Transitional arrangement?	no

Knee joint total endoprostheses

Overall result forecast presentation:	yes
Quantity performed reporting year:	28
Quantity forecast year:	55
Examination by state associations?	yes
Exemption?	no
Result of the examination by the federal state authorities?	no
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
CQ01	Quality assurance measures for inpatient care with the indication abdominal aortic aneurysm
CQ18	Measures for quality assurance of positron emission tomography in patients with Hodgkin lymphoma and aggressive non-Hodgkin lymphoma for interim staging after chemotherapy to decide on the continuation of therapy (Amended by resolution of July 15, 2021, see CQ29).

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
170	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*
93	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
74	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

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

Medikation- Anordnung und Abgabe

04.09.2018

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)

Anforderung und Abgabe von Arzneimitteln, Medikation - Anordnung und Abgabe, Umgang Arzneimittel, Umgang mit Betäubungsmittel, Medikationsprozess in der Pflege

18.01.2021

SOP on good prescription practices

Medikation-Anordnung und Abgabe

04.09.2018

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
Unit-Dose System, Iris-Kontrollsystem, Vier-Augen Prinzip

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)
Laborprogramm für Apotheken für die eingene Herstellung, Zenzy System für Chemotherapie Herstellung

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)
Pharmazeutische Freigabe der täglichen Medikation, Antibiotika-Beratung

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 des Medikationsplans
bei Bedarf Arzneimittel-Mitgabe oder Ausstellung von Entlassrezepten

Special instrument-based equipment

Research & teaching

Job

FL08 - Editors of scientific journals/textbooks

Explanation

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

Explanation

PanaMa Studie für Metastatic colorectal cancer, FOOTPATH Studie für metastatic pancreatic cancer., Alternative C Phase II, GOAL II

FL03 - Student training (clinical traineeship / internship year)

Explanation

In Zusammenarbeit mit dem Universitätsklinikum Hamburg Eppendorf UKE und dem Universitätsklinikum Schleswig-Holstein - Campus Kiel.

FL04 - Project-related cooperation with colleges and universities

Explanation

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

Explanation

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

FL09 - Doctoral supervision

Explanation

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

Explanation

ALTTO- Follow-Up (im Rahmen des HBZ) HD 21 Hodgkin Lymphom, ESCALADE bei B-Cell Lymphoma, CZAR-I, PREPARE 2.0 bei Nierenzellkarzinom, CIRCULATE bei Darmkrebs Stage II, NIS: Lungen carcinom CLL, CML, Nieren Ca.

FL01 - Lectureships / teaching posts at colleges and universities