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Klinikum rechts der Isar der Technischen Universität München - Biederstein

Biedersteiner Str. 29
80802 München

Phone: 089-4140-0
Mail: ed.mut.irm@dnatsrov

http://www.mri.tum.de
  • Number of beds: 67
  • Number of specialist departments: 1
  • Number of inpatient cases: 3.441
  • Number of outpatient cases: 31.912
  • Hospital owners: Freistaat Bayern
  • Type of provider: öffentlich
  • University Hospital
  • Academic teaching hospital
External comparative quality assurance
Further information
Bezeichnung
Teilnahme externe Qualitätssicherung yes
  • Quality of participation in the Disease Management Programme (DMP)
    No participation
Quantity performed 47
Exception? No exception
Quantity performed 78
Exception? No exception
Quantity performed 106
Exception? No exception
Quantity performed 145
Exception? No exception
Quantity performed 363
Exception? No exception
Quantity performed 24
Exception? No exception
Overall result forecast presentation: yes
Quantity performed reporting year: 47
Quantity forecast year: 35
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: 78
Quantity forecast year: 70
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: 106
Quantity forecast year: 122
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: 145
Quantity forecast year: 137
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: 363
Quantity forecast year: 403
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: 24
Quantity forecast year: 30
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: 467
Quantity forecast year: 477
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: 51
Quantity forecast year: 56
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
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
CQ28 Guideline on quality assurance measures for liposuction procedures for stage III lipedema (QS-RL Liposuction)
  • 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
518 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*
50 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
44 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.

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

siehe Erläuterungen unterhalb der Tabelle

19.09.2023

siehe Erläuterungen unterhalb der Tabelle

06.09.2023

siehe Erläuterungen unterhalb der Tabelle

06.09.2023

  • Bereitstellung einer geeigneten Infrastruktur zur Sicherstellung einer fehlerfreien Zubereitung
  • Zubereitung durch pharmazeutisches Personal
  • Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen
  • Vorhandensein von elektronischen Systemen zur Entscheidungsunterstützung (z.B. Meona®, Rpdoc®, AIDKlinik®, ID Medics® bzw. ID Diacos® Pharma)
  • 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)
  • Pharmakovigilanzmeldungen
  • klinikinterne Arzneimittelinformation durch pharmazeutisches Personal
  • 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

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Explanation

Kompetenznetz Medizinlehre Bayern

Explanation

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Explanation

Explanation

Training in other healing professions
Comment

Kooperation mit den Kliniken Freising und Erding und mehreren Berufsfachschulen

Comment

In Kooperation mit z.B. Hilfe im Alter, AWO Ebersberg, Asta ambulante Pflege GmbH, Klinikum Freising, Klinikum der Barmherzigen Schwestern, Klinikum Erding, kbo München Ost, Diakonie der Dankeskirche usw. und Pflegefachhelfer

Comment

Dr. Christine Maurer

Patientenfürsprecherin

Biedersteiner Str. 29
80802 München

Phone: 089 -4140-8506
Mail: ed.mut.irm@nirehcerpsreufnetneitap

PD Dr. Ursula Wandl

Patientenfürsprecherin

Biedersteiner Str. 29
80802 München

Phone: 089 -4140-8507
Mail: ed.mut.irm@nirehcerpsreufnetneitap

Kerstin Weber

Qualitätsmanagement, Beauftragte für "Meinungen und Vorschläge"

Biedersteiner Str. 29
80802 München

Phone: 089 -4140-7755
Mail: ed.mut.irm@vum

Dr. med. Angelika Werner

Leitung Qualitäts- und Risikomanagement (Ärztliche Direktion)

Biedersteiner Str. 29
80802 München

Phone: 089 -4140-7704
Mail: ed.mut.irm@renrew.akilegna

Dr. Martin Siess

Ärztlicher Direktor, Vorstandsvorsitzender

Biedersteiner Str. 29
80802 München

Phone: 089 -4140-7701
Mail: ed.mut.irm@noitkerid

Univ.-Prof. Dr. Florian Bassermann

Direktor Klinik und Poliklinik für Innere Medizin III

Biedersteiner Str. 29
80802 München

Phone: 089 -4140-4110
Mail: ed.mut@nnamressab.nairolf

Robert Peter

Schwerbehindertenvertreter

Biedersteiner Str. 29
80802 München

Phone: 089 -4140-7472
Mail: ed.mut.irm@gnutertrevnetrednihebrewhcS

Biedersteiner Str. 29
80802 München

Phone: 089-4140-0
Mail: ed.mut.irm@dnatsrov

Christoph Brakemeier

Stellv. der Pflegedirektorin

Biedersteiner Str. 29
80802 München

Phone: 089 -4140-2750
Mail: ed.mut.irm@noitkeridegelfp

Silke Großmann

Pflegedirektorin, Mitglied des Vorstands

Biedersteiner Str. 29
80802 München

Phone: 089 -4140-2750
Mail: ed.mut.irm@noitkeridegelfp

Christoph Brakemeier

Stellv. der Pflegedirektorin

Biedersteiner Str. 29
80802 München

Phone: 089 -4140-2750
Mail: ed.mut.irm@noitkeridegelfp

Marie Le Claire

Kaufmännische Direktorin, Mitglied des Vorstands

Biedersteiner Str. 29
80802 München

Phone: 089 -4140-2821
Mail: ed.mut.irm@noitkerid.ehcsinneamfuak

Toni Faas

Stellv. Kaufmännischer Direktor

Biedersteiner Str. 29
80802 München

Phone: 089 -4140-2809
Mail: ed.mut.irm@noitkerid.ehcsinneamfuak

Marie Le Claire

Kaufmännische Direktorin, Mitglied des Vorstands

Biedersteiner Str. 29
80802 München

Phone: 089 -4140-2821
Mail: ed.mut.irm@noitkerid.ehcsinneamfuak

Toni Faas

Stellv. Kaufmännischer Direktor

Biedersteiner Str. 29
80802 München

Phone: 089 -4140-2809
Mail: ed.mut.irm@noitkerid.ehcsinneamfuak

Dr. med. Martin Siess

Ärztlicher Direktor, Vorstandsvorsitzender

Biedersteiner Str. 29
80802 München

Phone: 089 -4140-7701
Mail: ed.mut.irm@noitkerid

Univ.-Prof. Dr. med. Tilo Biedermann

Stellv. Ärztlicher Direktor

Biedersteiner Str. 29
80802 München

Phone: 089 -4140-3170
Mail: ed.mut.irm@nnamredeiB.oliT

Dr. med. Martin Siess

Ärztlicher Direktor, Vorstandsvorsitzender

Biedersteiner Str. 29
80802 München

Phone: 089 -4140-7701
Mail: ed.mut.irm@noitkerid

Univ.-Prof. Dr. med. Tilo Biedermann

Stellv. Ärztlicher Direktor

Biedersteiner Str. 29
80802 München

Phone: 089 -4140-3170
Mail: ed.mut.irm@nnamredeiB.oliT

No

IK: 260913195

Location number: 772054000

Old location number: 772054000

Hospital portrait for download