Overall result forecast presentation:	yes
Quantity performed reporting year:	17
Quantity forecast year:	17
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Knee joint total endoprostheses

Overall result forecast presentation:	yes
Quantity performed reporting year:	104
Quantity forecast year:	142
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Surgical treatment of breast cancer (mamma surgery)

Overall result forecast presentation:	yes
Quantity performed reporting year:	231
Quantity forecast year:	239
Examination by state associations?	yes
Exemption?	yes
Result of the examination by the federal state authorities?	yes
Transitional arrangement?	no

Thoracic surgical treatment of lung cancer in adults

Overall result forecast presentation:	yes
Quantity performed reporting year:	66
Quantity forecast year:	64
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

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: no

Further training
pursuant to Article 136b, para. 1, sentence 1, no. 1 of the SGB

Number	Group
142	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*
142	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
127	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

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

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

Name of the working group: Arzneimittelkommission, ABS- Gruppe

Training of employees on AMTS related topics

Use of standardised forms for drug medical history

VA Arzneimittelanamnese

28.01.2021

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
Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen
Tabellen zum Lösen von Antibiotika

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)

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

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

Explanation

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

Explanation

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

FL03 - Student training (clinical traineeship / internship year)

Explanation

FL04 - Project-related cooperation with colleges and universities

Explanation

FL09 - Doctoral supervision

Explanation

Training

Training in other healing professions

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

Comment

Im Rahmen der Berufsausbildung werden in Kooperation mit der Ausbildungsstätte strukturierte Praktika am Marienhaus Klinikum Mainz absolviert.

HB17 - Auxiliary nurse (m/f)

Comment

Die theoretische und praktische Ausbildung wird an der Gesundheits- und Krankenpflegeschule in Zusammenarbeit mit den medizinischen Fachabteilungen des Marienhaus Klinikums Mainz und anderen externen Ausbildungsstätten absolviert.

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

Comment

Die theoretische und praktische Ausbildung wird an der Gesundheits- und Krankenpflegeschule in Zusammenarbeit mit den medizinischen Fachabteilungen des Marienhaus Klinikum Mainz und anderen externen Ausbildungsstätten absolviert.

HB06 - Occupational therapist (m/f)

Comment

Im Rahmen der Berufsausbildung werden in Kooperation mit der Ausbildungsstätte strukturierte Praktika am Marienhaus Klinikum Mainz absolviert.

HB10 - Midwife (m/f)

Comment

Im Rahmen der Berufsausbildung werden in Kooperation mit der Ausbildungsstätte strukturierte Praktika am Marienhaus Klinikum Mainz absolviert.

HB15 - Anaesthesia technical assistant (m/f)

Comment

Im Rahmen der Berufsausbildung werden in Kooperation mit der Ausbildungsstätte strukturierte Praktika am Marienhaus Klinikum Mainz absolviert.

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

Comment

Im Rahmen der Berufsausbildung werden in Kooperation mit der Ausbildungsstätte strukturierte Praktika am Marienhaus Klinikum Mainz absolviert.

HB09 - Speech therapist (m/f)

Comment

Im Rahmen der Berufsausbildung werden in Kooperation mit der Ausbildungsstätte strukturierte Praktika am Marienhaus Klinikum Mainz absolviert.

HB07 - Surgical technical assistant (m/f)

Comment

Im Rahmen der Berufsausbildung werden in Kooperation mit der Ausbildungsstätte strukturierte Praktika am Marienhaus Klinikum Mainz absolviert.

HB03 - Physical therapist / physiotherapist (m/f)

Comment

Im Rahmen der Berufsausbildung werden in Kooperation mit der Ausbildungsstätte strukturierte Praktika am Marienhaus Klinikum Mainz absolviert.

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

Comment

Im Rahmen der Berufsausbildung werden in Kooperation mit der Ausbildungsstätte strukturierte Praktika am Marienhaus Klinikum Mainz absolviert.

HB16 - Dietician (m/f)

Comment

Im Rahmen der Berufsausbildung werden in Kooperation mit der Ausbildungsstätte strukturierte Praktika am Marienhaus Klinikum Mainz absolviert.

HB19 - Nursing professionals

Comment

Generalistische Ausbildung zum/zur Pflegefachmann/-frau mit dem Schwerpunkt Akutpflege

HB20 - Nursing professional B. Sc.

Comment

Dualer Studiengang "Bachelor of Science (Pflege"

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 8
- Additional staff: 12
- Explanations: 7 Apotheker, davon 4 in Teilzeit plus 1 Stationsapotheker auf Intensivstation 12 PTA, davon 8 in Teilzeit
- Nursing staff regulation

Service contact persons

Patient advocates

Frau Dr. Sylvia Lorentz

Patientenfürsprecher

An der Goldgrube 11
55131 Mainz

Phone: 06131 -575-3333
Mail: ed.suahneiram@mkm.nirehcerpsreufnetneitap

Frau Gabriele Zorn-Schwarz

Patientenfürsprecher

An der Goldgrube 11
55131 Mainz

Phone: 06131 -575-3333
Mail: ed.suahneiram@mkm.nirehcerpsreufnetneitap

Customer feedback management

Frau Stephanie Heinz

Beschwerdemanagement

An der Goldgrube 11
55131 Mainz

Phone: 06131 -575-6000
Mail: ed.suahneiram@mkm.gnuniem-erhi

Frau Sabine Ruppert-Stahl

Krankenhausoberin

An der Goldgrube 11
55131 Mainz

Phone: 06131 -575-1631
Mail: ed.suahneiram@retnhezierd.ettenna

Frau Annette Dreizehnter

Qualitäts- und Risikomanagementbeauftragte, Lob- und Beschwerdemangerin

An der Goldgrube 11
55131 Mainz

Phone: 06131 -575-6000
Mail: ed.suahneiram@mkm.gnuniem-erhi

Quality management

Dipl.-Betriebswirtin (FH) Annette Dreizehnter

Qualitätsmanagement-Beauftragte (QMB)

An der Goldgrube 11
55131 Mainz

Phone: 06131 -575-2016
Mail: ed.suahneiram@retnhezierd.ettenna

Hygiene officer

Prof. Dr. med., MHBA Jörn Oliver Balzer

Ärztlicher Direktor

An der Goldgrube 11
55131 Mainz

Phone: 06131 -575-1700
Mail: ed.suahneiram@mkm.eigoloidar

Responsible for drug therapy

Dr. rer. nat. Peter Obitz

Leiter Apotheke und Einkauf

An der Goldgrube 11
55131 Mainz

Phone: 06131 -575-1180
Mail: ed.suahneiram@ztibo.retep

Accessibility Officer

Katja Hofmann

Sozialdienst und Pflegeüberleitung

An der Goldgrube 11
55131 Mainz

Phone: 06131 -575-1444
Mail: ed.suahneiram@nnamfoh.ajtak

Company

General contact details of the hospital

An der Goldgrube 11
55131 Mainz

Phone: 06131-5750
Fax: 06131-575-1610
Mail: ed.suahneiram@mkm.tkatnok

Nursing service management

Frau Marion Christian

Pflegedirektorin

An der Goldgrube 11
55131 Mainz

Phone: 06131 -575-2100
Mail: ed.suahneiram@mkm.tnemeganamegelfp

Frau Bettina Vor

Pflegedirektorin

An der Goldgrube 11
55131 Mainz

Phone: 06131 -575-2100
Mail: ed.suahneiram@mkm.tnemeganamegelfp

Head of administration

Dr. Klaus-Peter Reimund

Geschäftsführer

An der Goldgrube 11
55131 Mainz

Phone: 06131 -575-1600
Mail: ed.suahneiram@mkm.fgtairaterkes

Herr Philipp zu Löwenstein

Geschäftsführer

An der Goldgrube 11
55131 Mainz

Phone: 06131 -575-1600
Mail: ed.suahneiram@mkm.fgtairaterkes

Frau Sabine Ruppert-Stahl

Krankenhausoberin

An der Goldgrube 11
55131 Mainz

Phone: 06131 -575-1630
Mail: ed.suahneiram@lhats-treppur.enibas

Herr Christoph Wagner

Geschäftsführer

An der Goldgrube 11
55131 Mainz

Phone: 06131 -575-1600
Mail: ed.suahneiram@mkm.fgtairaterkes

Responsible for the quality report in the hospital management

Dr. Klaus-Peter Reimund

Geschäftsführer

An der Goldgrube 11
55131 Mainz

Phone: 06131 -575-1600
Mail: ed.suahneiram@fg.tairaterkes

Herr Philipp zu Löwenstein

Geschäftsführer

An der Goldgrube 11
55131 Mainz

Phone: 06131 -575-1600
Mail: ed.suahneiram@fg.tairaterkes

Herr Sascha Altendorf

Geschäftsführer (seit Oktober 2023)

An der Goldgrube 11
55131 Mainz

Phone: 06131 -575-1600
Mail: ed.suahneiram@fg.tairaterkes

Medical management

Prof. Dr. med. MHBA Jörn Oliver Balzer

Ärztlicher Direktor, Chefarzt der Klinik für Diagnostische und Interventionelle Radiologie

An der Goldgrube 11
55131 Mainz

Phone: 06131 -575-1700
Mail: ed.suahneiram@mkm.eigoloidar

Prof. Dr. med. Peter Härle

Stellv. ärztlicher Direktor, Chefarzt der Klinik für Rheumatologie, Klin. Immunologie und Phys. Therapie

An der Goldgrube 11
55131 Mainz

Phone: 06131 -575-1750
Mail: ed.suahneiram@mkm.eigolotamuehr

Priv.-Doz. Matthias David

Stellv. ärztlicher Direktor, Chefarzt der Klinik Anästhesie und Intensivmedizin

An der Goldgrube 11
55131 Mainz

Phone: 06131 -575-1250
Mail: ed.suahneiram@mkm.eisehtseana

Regional care obligation for psychiatry?

IK number

IK: 260730183

Location number

Location number: 772834000

Old location number: 772834000

Hospital portrait for download