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Klinikum Bayreuth

Klinikum Bayreuth
Klinikum Bayreuth

Preuschwitzer Straße 101
95445 Bayreuth

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

http://www.klinikum-bayreuth.de
  • Number of beds: 712
  • Number of specialist departments: 24
  • Number of inpatient cases: 25.275
  • Number of partial inpatient cases: 423
  • Number of outpatient cases: 29.414
  • Hospital owners: Klinikum Bayreuth GmbH
  • Type of provider: öffentlich
External comparative quality assurance
Further information
Bezeichnung
Teilnahme externe Qualitätssicherung yes
Diabetes mellitus Typ 2

Quantity performed 30
Exception? No exception
Quantity performed 4
Exception? No exception
Quantity performed 8
Exception? No exception
Quantity performed 14
Exception? No exception
Quantity performed 15
Exception? No exception
Overall result forecast presentation: Pending lawsuit
Quantity performed reporting year: 0
Quantity forecast year: 26
Examination by state associations? Pending lawsuit
Exemption? yes
Result of the examination by the federal state authorities? no
Transitional arrangement? no
Overall result forecast presentation: yes
Quantity performed reporting year: 30
Quantity forecast year: 26
Examination by state associations? yes
Exemption? yes
Result of the examination by the federal state authorities? yes
Transitional arrangement? no
Overall result forecast presentation: Pending lawsuit
Quantity performed reporting year: 4
Quantity forecast year: 6
Examination by state associations? Pending lawsuit
Exemption? yes
Result of the examination by the federal state authorities? no
Transitional arrangement? no
Overall result forecast presentation: Pending lawsuit
Quantity performed reporting year: 14
Quantity forecast year: 20
Examination by state associations? Pending lawsuit
Exemption? yes
Result of the examination by the federal state authorities? no
Transitional arrangement? no
Overall result forecast presentation: yes
Quantity performed reporting year: 15
Quantity forecast year: 21
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: 0
Quantity forecast year: 151
Examination by state associations? yes
Exemption? yes
Result of the examination by the federal state authorities? yes
Transitional arrangement? no
No. Explanation
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
CQ01 Quality assurance measures for inpatient care with the indication abdominal aortic aneurysm
CQ05 Measures for quality assurance in the care of pre-term and full-term neonates – Perinatal Centre LEVEL 1
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
165 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*
120 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
105 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.

  • Is a protection concept in place? Yes
  • Measures
    • 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.

      • 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)

  • 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.
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-Handbuch

16.10.2023

  • 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)
  • Zenzy, CATO seit 01.07.22
  • 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
  • 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

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Training in other healing professions
Comment

Generalistischen Ausbildung zum Pflegefachmann/- frau im Bereich Akutpflege und mit pädiatrischer Vertiefung

Comment

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in Kooperation mit der EAH Jena und Universiätat Erlangen

Comment

in Kooperation mit der Sozialstiftung Bamberg

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

Comment

in Kooperation mit Sozialstiftung Bamberg

Comment

Generalistischen Ausbildung zum Pflegefachmann/- frau im Bereich Akutpflege und mit pädiatrischer Vertiefung

Werner Keller

Patientenfürsprecher

Preuschwitzer Straße 101
95445 Bayreuth

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

Klaus Pietruska

Patientenfürsprecher

Preuschwitzer Straße 101
95445 Bayreuth

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

Alexander Weber

Abteilungsleiter Verbesserungs- und Beschwerdemanagement

Preuschwitzer Straße 101
95445 Bayreuth

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

Bianca Specht

Mitarbeiterin Verbesserungs- und Beschwerdemanagement

Preuschwitzer Straße 101
95445 Bayreuth

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

Claudia Maisel

Leiterin Qualitätsmanagement

Preuschwitzer Straße 101
95445 Bayreuth

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

Professor Dr. med. Hans-Rudolf Raab

Ärztlicher Direktor

Preuschwitzer Straße 101
95445 Bayreuth

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

Dr. Richard Sommerer

Apothekenleiter

Preuschwitzer Straße 101
95445 Bayreuth

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

Andreas Berghammer

Leiter Sozialdienst

Preuschwitzer Straße 101
95445 Bayreuth

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

Preuschwitzer Straße 101
95445 Bayreuth

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

Diplom-Pflegewirtin (FH) Angela Dzyck

Pflegedirektorin Klinikum Bayreuth GmbH

Preuschwitzer Straße 101
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)

Preuschwitzer Straße 101
95445 Bayreuth

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

Professor Dr. med. Hans-Rudolf Raab

Medizinischer Geschäftsführer und Ärztlicher Direktor

Preuschwitzer Straße 101
95445 Bayreuth

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

Alexander Mohr

Kaufmännischer Geschäftsführer

Preuschwitzer Straße 101
95445 Bayreuth

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

Dietmar Pawlik

Kaufmännischer Geschäftsführer ab 01.04.2023

Preuschwitzer Straße 101
95445 Bayreuth

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

Andreas Schumann

Leitung Geschäftsbereich Klinische Prozesse und Medizincontrolling

Preuschwitzer Straße 101
95445 Bayreuth

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

Professor Dr. med. Hans-Rudolf Raab

Medizinischer Geschäftsführer und Ärztlicher Direktor

Preuschwitzer Straße 101
95445 Bayreuth

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

Professor Dr. med. Hans-Rudolf Raab

Medizinischer Geschäftsführer und Ärztlicher Direktor

Preuschwitzer Straße 101
95445 Bayreuth

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

No

IK: 260940109

Location number: 772810000

Old location number: 772810000

Hospital portrait for download