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Niels-Stensen-Kliniken Marienhospital Osnabrück Standort Natruper Holz

Am Natruper Holz 69
49076 Osnabrück

Phone: 0541-326-0
Fax: 0541-681353
Mail: ed.ksn@ohm-ofni

https://www.niels-stensen-kliniken.de/niels-stense...

Basic information

Number of beds: 111
Number of specialist departments: 10

Number of inpatient cases: 6.038
Number of outpatient cases: 3.808

Hospital owners: Marienhospital Osnabrück GmbH (mit den Gesellschaftern Niels-Stensen-Kliniken GmbH und Bischöflicher Stuhl zu Osnabrück)
Type of provider: freigemeinnützig

Specialist departments

Services

Quality

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

Participation in other external comparative quality assurance procedures

Implementation of the minimum quantity agreement

Treatment area

Knee joint total endoprostheses

Quantity performed	171
Exception?	No exception

Minimum quantities forecast

Knee joint total endoprostheses

Overall result forecast presentation:	yes
Quantity performed reporting year:	171
Quantity forecast year:	184
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 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
40	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*
34	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
32	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
  Special requirements for the selection of persons
  Note on the measure
  Alle Mitarbeitenden müssen eine entsprechende Straffreiheitserklärung abgeben.
  Education
  Code of conduct with rules for treating children and young people with respect
  Note on the measure
  Alle Mitarbeitenden müssen eine Selbstverpflichtungserklärung abgeben.
  
  Last review of the measure
  29.12.2021 19:30:10
  Training of employees
  
  Information gathering on the topic

Alle Mitarbeitenden müssen eine entsprechende Straffreiheitserklärung abgeben.

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

Verfahrensanweisung Arzneimitteltherapiesicherheit Nr. 005788

14.03.2024

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)

Empfehlungen zum Richten und Stellen von Tabletten Nr. 015128

14.03.2024

SOP on good prescription practices

Arzneimitteltherapiesicherheit Nr. 005788, Umgang mit Betäubungsmitteln Verfahrensanweisung, Dokumenten-Nr.: 015648

14.03.2024

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

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)
Bei Bestellung, Herstellung und Abgabe von Arzneimitteln werden eingesetzt:MMI Pharmaindex, AMeLI, MobiDik, Zenzy, Dr. Lennartz Laborprogramm

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)
Umsetzung 4-Augen-Prinzip, Einführung von Stationsapotheker*innen inklusive Begehungen der Stationen, Risikoaudits im Bereich AMTS, Erstellung von Verfahrensanweisungen zur AMTS, Verwendung von DIVI-Spritzenaufkleber, getrennte Aufbewahrung von „Look alike“ und „Sound alike“- Arzneimitteln

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
EntlassrezeptenÄrztliches und pflegerisches Entlassungsgespräch; Verfahrensanweisung zur Verordnung von Betäubungsmitteln im Rahmen des Entlassungsmanagements

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

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

Explanation

Wir führen Studien u. a. zu folgenden Krankheitsentitäten durch: – Morbus Hodgkin- - - - Multiple Sklerose -

FL08 - Editors of scientific journals/textbooks

Explanation

In mehreren Bereichen zu unterschiedlichsten Themen.

FL04 - Project-related cooperation with colleges and universities

Explanation

Kooperation mit mehreren Universitäten und Hochschulen.

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

Insb. Chefärzte als Professoren oder Privat-Dozenten an Universitäten.

FL09 - Doctoral supervision

Explanation

In mehreren Bereichen zu unterschiedlichsten Themen.

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

Lehraufträge zu verschiedenen Themen.

FL03 - Student training (clinical traineeship / internship year)

Explanation

Das Marienhospital Osnabrück ist akademisches Lehrkrankenhaus der Medizinischen Hochschule Hannover.

Training

Training in other healing professions

HB07 - Surgical technical assistant (m/f)

Comment

In Kooperation mit dem Niels Stensen Bildungszentrum

HB15 - Anaesthesia technical assistant (m/f)

Comment

In Kooperation mit dem Niels Stensen Bildungszentrum

HB17 - Auxiliary nurse (m/f)

Comment

In Kooperation mit Pflegefachschulen

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

Comment

Praktische Ausbildung in Kooperation mit mehreren Rettungswachen

HB19 - Nursing professionals

Comment

In Kooperation mit dem Niels Stensen Bildungszentrum

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

Comment

in Kooperation mit der Akademie am Klinikum Osnabrück

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

Comment

In Kooperation mit dem Niels Stensen Bildungszentrum

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 21
- Additional staff: 27
- Explanations: Das Marienhospital Osnabrück gehört dem Verbund der Niels-Stensen-Kliniken mit einer Zentralapotheke an. Die dort tätigen Apotheker und Apothekerinnen sowie weiteres pharmazeutisches Personal sind auch für unsere Einrichtung tätig.
- Nursing staff regulation