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Klinik Viktoriastift

Cecilienhöhe 3
55543 Bad Kreuznach

https://www.landeskrankenhaus.de/klinik-viktoriast...

Basic information

Number of beds: 20
Number of specialist departments: 2

Number of inpatient cases: 27
Number of partial inpatient cases: 28
Number of outpatient cases: 536

Hospital owners: Landeskrankenhaus (AöR)
Type of provider: öffentlich

Specialist departments

Services

Quality

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 participation

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
7	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*
7	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
1	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
  Training of employees
  Note on the measure
  Das Landeskrankenhaus (AöR) schult Mitarbeitende, die mit Kindern und Jugendlichen arbeiten, gezielt im Rahmen einer regelm. Fortbildung über die interne Fortbildungsakademie. Die Teilnahme ist verpflichtend alle zwei Jahre nachzuweisen. Konkrete Inhalte sind im Kinderschutzkonzept festgelegt.
  Information gathering on the topic
  Note on the measure
  Das Kinderschutzkonzept des Trägers befasst sich u.a. mit dem aktuellen Wissensstand zur Thematik sowie zur Möglichkeit der Informationsgewinnung (u.a. "Risiken erkennen und minimieren" / "Identifizierung von Problembereichen").
  Education
  Note on the measure
  Verankerung in bestehenden Strukturen / verpflichtende Fortbildungen / Mitarbeitersensibilisierung > Kinderschutzkonzept des Trägers (LKH)
  Code of conduct with rules for treating children and young people with respect
  Note on the measure
  Der Verhaltenskodex ist im Kinderschutzkonzept des Trägers (LKH) niedergelegt.
  
  Last review of the measure
  05.11.2021 19:31:23
  Age-appropriate complaint options
  Note on the measure
  Regelungen u.a. zu Meldemöglichkeiten sind im Kinderschutzkonzept konkretisiert.
- Intervention
  Intervention plan - Binding procedure for dealing with child protection cases and in particular suspected (sexual) violence
  Note on the measure
  Vgl. bei SK10
  
  Last review of the measure
  05.11.2021 19:31:23
- Review
  Recommendations for dealing with/processing cases that have occurred
  Note on the measure
  Der Umgang mit konkreten Verdachtsfällen, zu internen und externen Ansprechpartner:innen, zur Kommunikation, zur Dokumentation bis hin zur Rehabilitation fälschlich verdächtigter Personen sind im Kinderschutzkonzept (LKH) geregelt.
  
  Last review of the measure
  05.11.2021 19:31:23

Das Landeskrankenhaus (AöR) schult Mitarbeitende, die mit Kindern und Jugendlichen arbeiten, gezielt im Rahmen einer regelm. Fortbildung über die interne Fortbildungsakademie. Die Teilnahme ist verpflichtend alle zwei Jahre nachzuweisen. Konkrete Inhalte sind im Kinderschutzkonzept festgelegt.

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

Use of standardised forms for drug medical history

Aufklärungsbögen Firma Thieme

09.05.2023

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)

LKH Konzept zur Anwendung von und zum Umgang mit Arzneimitteln. RFK Konzept zur Anwendung und zum Umgang mit Betäubungsmitteln.

18.04.2023

SOP on good prescription practices

Leitlinie Antibiotikatherapie

02.07.2024

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
CGM MUSE als bestell- und Informationssystem für alle Stationsmitarbeiter und Ärzte. Workflow mit gestaffelten Freigaberechten

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)
CGM MUSE als Bestell- und Informationssystem für Stationsmitarbeiter und Ärzte. Workflow mit gestaffelten Freigaberechten

Electronic documentation of the administration of drugs

Measures to minimise medication errors

Fallbesprechungen
Maßnahmen zur Vermeidung von Arzneimittelverwechslung
Teilnahme an einem einrichtungsübergreifenden Fehlermeldesystem (siehe Kapitel 12.2.3.2)
Validierung jeder Sonderanforderung unter Nutzung der Angaben im KIS System durch einen Apotheker

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

FL04 - Project-related cooperation with colleges and universities

Explanation

Training

Training in other healing professions

HB06 - Occupational therapist (m/f)

Comment

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

Comment

HB16 - Dietician (m/f)

Comment

HB17 - Auxiliary nurse (m/f)

Comment

HB03 - Physical therapist / physiotherapist (m/f)

Comment

HB02 - Health and paediatric nurse (m/f)

Comment

HB19 - Nursing professionals

Comment

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 4
- Additional staff: 4
- Explanations: Es liegt ein Versorgungsvertrag vor, der die Versorgung mit Arzneimitteln und Medizinprodukten durch die Apotheke der RFK Alzey vorsieht. Pharmazeutisches Personal für verantwortlich für alle zu beliefernden Einrichtungen. Apotheker: 3 Vollzeit, 1 Teilzeit. PTA: alle Teilzeit