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St. Josef-Hospital

St. Josef-Hospital
St. Josef-Hospital

Gudrunstraße 56
44791 Bochum

Phone: 0234-509-0
Mail: ed.muhcob-mukinilk@ofni

  • Number of beds: 645
  • Number of specialist departments: 15
  • Number of inpatient cases: 29.819
  • Number of outpatient cases: 168.019
  • Hospital owners: Katholisches Klinikum Bochum gGmbH
  • Type of provider: freigemeinnützig
  • University Hospital
  • Academic teaching hospital
External comparative quality assurance
Further information
  • External quality assurance according to state law
    No participation
Quantity performed 16
Exception? No exception
Quantity performed 176
Exception? No exception
Overall result forecast presentation: yes
Quantity performed reporting year: 176
Quantity forecast year: 177
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: 16
Quantity forecast year: 15
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
  • 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
Number Group
205 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*
127 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”

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
      • Note on the measure

        Bei der Entwicklung des ISK war eine interdisziplinäre und interprofessionelle AG aktiv, bei der z. B. die Kinderklinik eine übergeordnete Rolle gespielt hat.

    • Intervention
    • Review
  • Bei der Entwicklung des ISK war eine interdisziplinäre und interprofessionelle AG aktiv, bei der z. B. die Kinderklinik eine übergeordnete Rolle gespielt hat.
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 commission
  • Bereitstellung einer geeigneten Infrastruktur zur Sicherstellung einer fehlerfreien Zubereitung
  • Zubereitung durch pharmazeutisches Personal
  • Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen
  • Bestellung der Arzneimittel über ein Online-Bestellsystem. Bestellung zum Teil nur mit Patientenbezug möglich. Bestellung patientenindividueller Zytostatikazubereitungen über ein Online-Arztmodul
  • Spezielle AMTS-Visiten (z. B. pharmazeutische Visiten, antibiotic stewardship, Ernährung)
  • Abgabe von oralen Zytostatika nur patientenbezogen. Abgabe von oralen und s.c. MTX nur patientenbezogen für einen Applikationstag
  • 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
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.
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Training in other healing professions
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Anita Loest

Patientenfürsprecherin

Gudrunstraße 56
44791 Bochum

Phone: 0234 -509-3752
Mail: ed.muhcob-mukinilk@tseol.atina

Heinz Loest

Patiententfürsprecher

Gudrunstraße 56
44791 Bochum

Phone: 0234 -509-8682
Mail: ed.muhcob-mukinilk@tseol.znieh

Yelda Dalyanoglu

Beschwerdemanagement

Gudrunstraße 56
44791 Bochum

Phone: 0234 -509-0
Mail: ed.muhcob-mukinilk@edrewhcseb

Heike Fabian

Qualitätsmanagementbeauftragte

Gudrunstraße 56
44791 Bochum

Phone: 0234 -509-0
Mail: ed.muhcob-mukinilk@edrewhcseb

Dr. Andreas Hellwig

Geschäftsbereichsleiter Medizinmanagement

Gudrunstraße 56
44791 Bochum

Phone: 0234 -509-8899
Mail: ed.oblkk@mq

Prof. Dr. Eggert Stockfleth

Ärztlicher Direktor

Gudrunstraße 56
44791 Bochum

Phone: 0234 -509-3411
Mail: ed.oblkk@rotkeridrehciltzrea

Dr. Irmgard Plößl

Leiterin Zentralapotheke

Gudrunstraße 56
44791 Bochum

Phone: 0234 -509-2727
Mail: ed.muhcob-mukinilk@lsseolp.dragmri

Dirk Häger

Leiter Sozialdienst

Gudrunstraße 56
44791 Bochum

Phone: 0234 -509-2136
Mail: ed.muhcob-mukinilk@regeah.krid

Sabine Kesting

Pflegedirektorin

Gudrunstraße 56
44791 Bochum

Phone: 0234 -509-2125
Mail: ed.oblkk@gnitsek.enibas

Dr. Christian Raible

Kaufmännischer Geschäftsführer

Gudrunstraße 56
44791 Bochum

Phone: 0234 -509-3700
Mail: ed.oblkk@elbiar.naitsirhc

Dr. Christian Raible

Kaufmännischer Geschäftsführer

Gudrunstraße 56
44791 Bochum

Phone: 0234 -509-3700
Mail: ed.oblkk@elbiar.naitsirhc

Prof. Dr. Christoph Hanefeld

Medizinischer Geschäftsführer

Gudrunstraße 56
44791 Bochum

Phone: 0234 -509-8251
Mail: ed.oblkk@dlefenah.hpotsirhc

IK: 260590071

Location number: 772744000

Old location number: 772744000

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