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Universitätsklinikum Münster

Domagkstr. 5
48149 Münster

Phone: 0251-83-55555
Fax: 0251-83-55803
Mail: ed.retsneumku@ofni

http://www.ukm.de
  • Number of beds: 1.621
  • Number of specialist departments: 50
  • Number of inpatient cases: 47.208
  • Number of partial inpatient cases: 4.920
  • Number of outpatient cases: 378.581
  • Hospital owners: Land Nordrhein-Westfalen
  • Type of provider: öffentlich
  • University Hospital
  • Academic teaching hospital
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
Quantity performed 208
Exception? No exception
Quantity performed 71
Exception? No exception
Quantity performed 86
Exception? No exception
Quantity performed 67
Exception? No exception
Quantity performed 52
Exception? No exception
Quantity performed 71
Exception? No exception
Quantity performed 25
Exception? No exception
Overall result forecast presentation: yes
Quantity performed reporting year: 208
Quantity forecast year: 157
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: 71
Quantity forecast year: 65
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: 86
Quantity forecast year: 101
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: 67
Quantity forecast year: 63
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: 52
Quantity forecast year: 51
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: 71
Quantity forecast year: 86
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: 25
Quantity forecast year: 19
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: 516
Quantity forecast year: 521
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: 95
Quantity forecast year: 91
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
CQ02 Quality assurance measures for the inpatient care of children and adolescents with haemato-oncological diseases
CQ03 Quality assurance measures for the implementation of positron emission tomography (PET) in hospitals for the indications non-small-cell lung cancer (NSCLC) and solid pulmonary nodules
CQ05 Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 1
CQ08 Measures for quality assurance of cardiac surgery care in children and adolescents according to Article 136, para. 1, sentence 1, no. 2 of the SGB V
CQ24 Quality assurance measures for allogeneic stem cell transplantation for multiple myeloma (valid until 30 June 2022)
CQ25 Measures for quality assurance in the performance of minimally invasive heart valve interventions pursuant to Article 136, para. 1, sentence 1, number 2 for hospitals licensed in accordance with Article 108 of the SGB V
  • 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
Number Group
773 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*
113 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
73 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.

  • Liegt schriftlich vor.
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

QM-Plattform Nexus Curator

09.05.2023

QM-Plattform Nexus Curator

09.05.2023

QM-Plattform Nexus Curator

09.05.2023

  • Bereitstellung einer geeigneten Infrastruktur zur Sicherstellung einer fehlerfreien Zubereitung
  • Zubereitung durch pharmazeutisches Personal
  • Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen
  • elektronische Unterstützung bei der Bestellung
  • 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)
  • 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
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.
Job
Explanation

Explanation

Explanation

siehe: https://www.medizin.uni-muenster.de/fakultaet/studium.html

Explanation

Mitarbeit an zahlreichen Verbundforschungsprojekten, EU-Projekten, Kompetenznetzen, anderen Netzwerken etc. siehe: https://www.medizin.uni-muenster.de/fakultaet/forschung/verbundforschung.html

Explanation

Kontakt: https://www.medizin.uni-muenster.de/zks/das-zks/

Explanation

Kontakt: https://www.medizin.uni-muenster.de/zks/das-zks/

Explanation

Uni- als auch multizentrische Studien werden initiiert. Es bestehen Beteiligungen an und Leitungen von uni- als auch multizentrischen klinisch-wissenschaftlichen Studien. Kontakt: https://www.medizin.uni-muenster.de/zks/das-zks/

Explanation

Zahlreiche Herausgeberschaften und Mitherausgeberschaften in wissenschaftlichen Journalen/Lehrbüchern sowie weit über 100 Mitgliedschaften in Editorial oder Advisory Boards

Explanation

siehe: https://www.medizin.uni-muenster.de/fakultaet/forschung/foerderung-karriere/promotion-organisieren/

Training in other healing professions
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Prof. Dr. Dr. Gerhard Brodner

Patientenfürsprecher

Domagkstr. 5
48149 Münster

Phone: 0251 -8354545-
Mail: ed.retsneum@ehcarpsreufnetneitap

Prof. Dr. Thomas Prien

Patientenfürsprecher

Domagkstr. 5
48149 Münster

Phone: 0251 -8354545-
Mail: ed.retsneum@ehcarpsreufnetneitap

Norbert Schöppner

Patientenfürsprecher, Amtsrichter a.D.

Domagkstr. 5
48149 Münster

Phone: 0251 -8354545-
Mail: ed.retsneum@ehcarpsreufnetneitap

Iris Zander

Ansprechpartnerin

Domagkstr. 5
48149 Münster

Phone: 0251 -83-58500
Mail: ed.retsneumku@kitirkdnubol

Christina Kötting

Ansprechpartnerin

Domagkstr. 5
48149 Münster

Phone: 0251 -83-58500
Mail: ed.retsneumku@kitirkdnubol

Ann Christin Hessing

Ansprechpartnerin

Domagkstr. 5
48149 Münster

Phone: 0251 -83-58500
Mail: ed.retsneumku@kitirkdnubol

Helene Grad

Leitung des Geschäftsbereiches ZQRM

Domagkstr. 5
48149 Münster

Phone: 0251 -83-52028
Mail: ed.retsneumku@mrqz

Univ.-Prof. Dr. med. Alex W. Friedrich

Ärztlicher Direktor des UKM

Domagkstr. 5
48149 Münster

Phone: 0251 -83-52020
Mail: ed.retsneumku@rotkerid.rehciltzrea

Dr. rer. nat. Christoph Klaas

Apothekenleiter

Domagkstr. 5
48149 Münster

Phone: 0251 -83-48843
Mail: ed.retsneumku@saalk.hpotsirhc

Vogelpohl Lydia

Vertrauensfrau der schwerbehinderten Beschäftigten

Domagkstr. 5
48149 Münster

Phone: 0251 -83-55969
Mail: ed.retsneumku@gnutertrevnetrednihebrewhcs

Domagkstr. 5
48149 Münster

Phone: 0251-83-55555
Fax: 0251-83-55803
Mail: ed.retsneumku@ofni

Thomas van den Hooven

Pflegedirektor

Domagkstr. 5
48149 Münster

Phone: 0251 -83-48022
Mail: ed.retsneumku@nevoohnednav.samoht

Dr. rer.pol. Christoph Hoppenheit

Kaufmännischer Direktor

Domagkstr. 5
48149 Münster

Phone: 0251 -83-55802
Mail: ed.retsneumku@tiehneppoH.hpotsirhC

Helene Grad

Leiterin Zentrales Qualitäts- u. klinisches Risikomanagement

Domagkstr. 5
48149 Münster

Phone: 0251 -83-52028
Mail: ed.retsneumku@darG.eneleH

Univ.-Prof. Dr. med. Alex W. Friedrich

Ärztlicher Direktor ab 01.01.2022

Domagkstr. 5
48149 Münster

Phone: 0251 -83-52020
Mail: ed.retsneumku@rotkerid.rehciltzrea

No

IK: 260550131

Location number: 772432000

Hospital portrait for download