Overall result forecast presentation:	yes
Quantity performed reporting year:	148
Quantity forecast year:	140
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
66	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*
43	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
41	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
  Other aspects of prevention
  Note on the measure
  Die Kinderschutzgruppe am Klinikum Bayreuth (ärztliche und pflegerische Mitarbeiter*innen) trifft sich 1x im Quartal zum "Runden-Tisch Kinderschutz" mit Fachkräften der Jugendämter im Umkreis.
  Training of employees
  Note on the measure
  Regelmäßige Teilnahme von Mitarbeiterinnen der Pflege der Kinderklinik und Geburtshilfe:
  an runden Tischen zu Themen des Kinder- und Jugendschutzes und an Jahrestagungen am Netzwerk frühe Kindheit (KoKi)
  Information gathering on the topic

Die Kinderschutzgruppe am Klinikum Bayreuth (ärztliche und pflegerische Mitarbeiter*innen) trifft sich 1x im Quartal zum "Runden-Tisch Kinderschutz" mit Fachkräften der Jugendämter im Umkreis.

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

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)

QM-Handbuch

16.10.2023

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)
Zenzy, CATO seit 01.07.22

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)
teilweise Einzeldosisanforderung

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

FL09 - Doctoral supervision

Explanation

FL01 - Lectureships / teaching posts at colleges and universities

Explanation

FL07 - Initiation and management of uni-centric/multi-centric clinical/scientific studies

Explanation

FL04 - Project-related cooperation with colleges and universities

Explanation

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

Explanation

FL05 - Participation in multi-centre Phase I/II studies

Explanation

FL03 - Student training (clinical traineeship / internship year)

Explanation

Training

Training in other healing professions

HB12 - Medical technical laboratory assistant (MTLA) (m/f)

Comment

60 Ausbildungsplätze

HB10 - Midwife (m/f)

Comment

In Kooperation mit der Sozialstiftung Bamberg

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

Comment

90 Ausbildungsplätze im Rahmen der generalistischen Ausbildung

HB07 - Surgical technical assistant (m/f)

Comment

4 Ausbildungsplätze; in Kooperation mit der Sozialstiftung Bamberg

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

Comment

3 Ausbildungsplätze; in Kooperation mit dem BSZG Erlangen (Staatliches Berufliches Schulzentrum für Gesundheitsberufe Erlangen)

HB17 - Auxiliary nurse (m/f)

Comment

16 Ausbildungsplätze

HB02 - Health and paediatric nurse (m/f)

Comment

48 Ausbildungsplätze im Rahmen der generalistischen Ausbildung

HB03 - Physical therapist / physiotherapist (m/f)

Comment

90 Ausbildungsplätze

HB19 - Nursing professionals

Comment

Hospital staff
Pharmaceutical personnel
- Explanations: Pharmazeutisches Personal ist der Betriebsstätte Klinikum zugeordnet.
- Nursing staff regulation

Service contact persons

Patient advocates

Klaus Pietruska

Patietenfürsprecher

Hohe Warte 8
95445 Bayreuth

Phone: 0921 -400-2033
Mail: ed.htueryab-mukinilk@rehcerpsreufnetneitap

Werner Keller

Patientenfürsprecher

Hohe Warte 8
95445 Bayreuth

Phone: 0921 -400-2033
Mail: ed.htueryab-mukinilk@rehcerpsreufnetneitap

Customer feedback management

Alexander Weber

Abteilungsleiter Verbesserungs- und Beschwerdemanagement

Hohe Warte 8
95445 Bayreuth

Phone: 0921 -400-2030
Mail: ed.htueryab-mukinilk@tnemeganamsgnuressebrev

Bianca Specht

Mitarbeiterin Verbesserungs- und Beschwerdemanagement

Hohe Warte 8
95445 Bayreuth

Phone: 0921 -400-2032
Mail: ed.htueryab-muinilk@tnemeganamsgnuressebrev

Quality management

Claudia Maisel

Leiterin Qualitätsmanagement

Hohe Warte 8
95445 Bayreuth

Phone: 0921 -400-2040
Mail: ed.htueryab-mukinilk@lesiam.aidualc

Hygiene officer

Professor Dr. med. Hans-Rudolf Raab

Ärztlicher Direktor

Hohe Warte 8
95445 Bayreuth

Phone: 0921 -400-3001
Mail: ed.htueryab-mukinilk@fg.dem

Responsible for drug therapy

Dr. Richard Sommerer

Apothekenkeiter

Hohe Warte 8
95445 Bayreuth

Phone: 0921 -400-2400
Mail: ed.htueryab-mukinilk@reremmos.drahcir

Accessibility Officer

Andreas Berghammer

Leiter Sozialdienst

Hohe Warte 8
95445 Bayreuth

Phone: 0921 -400-4670
Mail: ed.htueryab-mukinilk@remmahgreb.saerdna

Company

General contact details of the hospital

Hohe Warte 8
95445 Bayreuth

Phone: 0921-400-0
Fax: 0921-400-882002
Mail: ed.htueryab-mukinilk@elletstsop

Nursing service management

Diplom-Pflegewirtin (FH) Angela Dzyck

Pflegedirektorin Klinikum Bayreuth GmbH

Hohe Warte 8
95445 Bayreuth

Phone: 0921 -400-1000
Mail: ed.htueryab-mukinilk@kcyzd.alegna

M.A. Personal und Arbeit Franziska Maidorn

Pflegedirektorin ab 01.11.2023 (kommissarisch vom 01.04.2023 bis 31.10.2023)

Hohe Warte 8
95445 Bayreuth

Phone: 0921 -400-1000
Mail: ed.htueryab-mukinilk@nrodiam.aksiznarf

Head of administration

Professor Dr. med. Hans-Rudolf Raab

Medizinischer Geschäftsführer und Ärztlicher Direktor

Hohe Warte 8
95445 Bayreuth

Phone: 0921 -400-3001
Mail: ed.htueryab-mukinilk@fg.dem

Alexander Mohr

Kaufmännischer Geschäftsführer

Hohe Warte 8
95445 Bayreuth

Phone: 0921 -400-2001
Mail: ed.htueryab-mukinilk@fg.mfk

Dietmar Pawlik

Kaufmännischer Geschäftsführer ab 01.04.2023

Hohe Warte 8
95445 Bayreuth

Phone: 0921 -400-2001
Mail: ed.htueryab-mukinilk@fg.mfk

Responsible for the quality report in the hospital management

Andreas Schumann

Leitung Geschäftsbereich Klinische Prozesse und Medizincontrolling

Hohe Warte 8
95445 Bayreuth

Phone: 0921 -400-2200
Mail: ed.htueryab-mukinilk@nnamuhcs.saerdna

Professor Dr. med. Hans-Rudolf Raab

Medizinischer Geschäftsführer und Ärztlicher Direktor

Hohe Warte 8
95445 Bayreuth

Phone: 0921 -400-3001
Mail: ed.htueryab-mukinilk@fg.dem

Medical management

Professor Dr. med. Hans-Rudolf Raab

Medizinischer Geschäftsführer und Ärztlicher Direktor

Hohe Warte 8
95445 Bayreuth

Phone: 0921 -400-3001
Mail: ed.htueryab-mukinilk@fg.dem

Regional care obligation for psychiatry?

IK number

IK: 260940109

Location number

Location number: 772661000

Old location number: 772661000

Hospital portrait for download