Overall result forecast presentation:	yes
Quantity performed reporting year:	688
Quantity forecast year:	740
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
31	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*
7	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
5	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
No care for children and young people

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

Use of standardised forms for drug medical history

Qualitätsmanagement-Handbuch

23.06.2016

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)

SOP on good prescription practices

Qualitätsmanagement-Handbuch

23.06.2016

Concepts for ensuring the error-free preparation of medications

Bereitstellung einer geeigneten Infrastruktur zur Sicherstellung einer fehlerfreien Zubereitung
Anwendung von gebrauchsfertigen Arzneimitteln bzw. Zubereitungen
Zubereitung durch pharmazeutisches Personal im Sinne der Herstellung weniger Produkte durch die externe Apotheke

Measures to minimise medication errors

Fallbesprechungen
Maßnahmen zur Vermeidung von Arzneimittelverwechslung

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 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

FL02 - Lectureships / teaching posts at universities of applied sciences

Explanation

FL04 - Project-related cooperation with colleges and universities

Explanation

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

Explanation

Training

Training in other healing professions

HB19 - Nursing professionals

Comment

In Kooperation mit den Oberlin Beruflichen Schulen, St. Josefs-Krankenhaus und Evangelischen Zentrum für Altersmedizin

HB17 - Auxiliary nurse (m/f)

Comment

In Kooperation mit dem Gesundheitscampus Potsdam

HB15 - Anaesthesia technical assistant (m/f)

Comment

In Kooperation mit dem Gesundheitscampus Potsdam

HB07 - Surgical technical assistant (m/f)

Comment

In Kooperation mit dem Gesundheitscampus Potsdam

Hospital staff
Pharmaceutical personnel
- Number of pharmacists: 4
- Additional staff: 4
- Explanations: extern versorgende Apotheke
- Nursing staff regulation

Service contact persons

Patient advocates

Frank Spade

Patientenfürsprecher

Rudolf-Breitscheid-Str. 24
14482 Potsdam

Phone: 0331 -763-4312
Mail: ed.suahnilrebo@rehcerpsreufnetneitap

Customer feedback management

Julia Wiedau

Qualitätsmanagementbeauftragte (seit 01.06.2020)

Rudolf-Breitscheid-Str. 24
14482 Potsdam

Phone: 0331 -763-4325
Mail: ed.kinilk-nilrebo@ofni

Katharina Bärenklau

Öffentlichkeitsarbeit

Rudolf-Breitscheid-Str. 24
14482 Potsdam

Phone: 0331 -763-4325
Mail: ed.kinilk-nilrebo@ofni

Jennifer Menzel

Öffentlichkeitsarbeit

Rudolf-Breitscheid-Str. 24
14482 Potsdam

Phone: 0331 -763-4325
Mail: ed.kinilk-nilrebo@ofni

Quality management

Julia Wiedau

Qualitätsmanagementbeauftragte (seit 01.06.2020)

Rudolf-Breitscheid-Str. 24
14482 Potsdam

Phone: 0331 -763-4325
Mail: ed.kinilk-nilrebo@ofni

Ruth Dörnhöfer (i.V. QM)

Verwaltungsdirektion

Rudolf-Breitscheid-Str. 24
14482 Potsdam

Phone: 0331 -763-4325
Mail: ed.kinilk-nilrebo@ofni

Ruth Dörnhöfer

Verwaltungsdirketorin

Rudolf-Breitscheid-Str. 24
14482 Potsdam

Phone: 0331 -763-4325
Mail: ed.kinilk-nilrebo@ofni

Hygiene officer

Dr. med. Robert Krause

Ärztlicher Direktor, Chefarzt

Rudolf-Breitscheid-Str. 24
14482 Potsdam

Phone: 0331 -763-4315
Mail: ed.kinilk-nilrebo@ofni

Responsible for drug therapy

Dr. med. Wolf Schildberg

OA Anästhesie

Rudolf-Breitscheid-Str. 24
14482 Potsdam

Phone: 0331 -763-4264
Mail: ed.kinilk-nilrebo@ofni

Accessibility Officer

Birgit Kruse

Sozialdienst

Rudolf-Breitscheid-Str. 24
14482 Potsdam

Phone: 0331 -763-4141
Mail: ed.suahnilrebo@tsneidlaizos

Petra Weidlich

Sozialdienst

Rudolf-Breitscheid-Str. 24
14482 Potsdam

Phone: 0331 -763-4141
Mail: ed.suahnilrebo@tsneidlaizos

Company

General contact details of the hospital

Rudolf-Breitscheid-Str. 24
14482 Potsdam

Phone: 0331-7634312
Fax: 0331-763-4322
Mail: ed.kinilk-nilrebo@ofni

Nursing service management

Caterina Lau

Komm. Pflegedirektorin

Rudolf-Breitscheid-Str. 24
14482 Potsdam

Phone: 0331 -763-4325
Mail: ed.kinilk-nilrebo@ofni

Head of administration

Andreas Koch

Geschäftsführer

Rudolf-Breitscheid-Str. 24
14482 Potsdam

Phone: 0331 -763-4325
Mail: ed.kinilk-nilrebo@ofni

Oliver Pommerenke

Geschäftsführer

Rudolf-Breitscheid-Str. 24
14482 Potsdam

Phone: 0331 -763-4325
Mail: ed.kinilk-nilrebo@ofni

Ruth Dörnhöfer

Verwaltungsdirektorin

Rudolf-Breitscheid-Str. 24
14482 Potsdam

Phone: 0331 -763-4325
Mail: ed.kinilk-nilrebo@ofni

Alexander Mommert

Geschäftsführer

Rudolf-Breitscheid-Str. 24
14482 Potsdam

Phone: 0331 -763-4302
Mail: ed.kinilk-nilrebo@ofni

Responsible for the quality report in the hospital management

Oliver Pommerenke

Geschäftsführer

Rudolf-Breitscheid-Str. 24
14482 Potsdam

Phone: 0331 -763-4325
Mail: ed.kinilk-nilrebo@ofni

Andreas Koch

Geschäftsführer

Rudolf-Breitscheid-Str. 24
14482 Potsdam

Phone: 4325 -763-4325
Mail: ed.kinilk-nilrebo@ofni

Ruth Dörnhöfer

Verwaltungsdirektorin

Rudolf-Breitscheid-Str. 24
14482 Potsdam

Phone: 0331 -763-4325
Mail: ed.kinilk-nilrebo@ofni

Medical management

Dr. med. Robert Krause

Ärztlicher Direktor

Rudolf-Breitscheid-Str. 24
14482 Potsdam

Phone: 0331 -763-4315
Mail: ed.kinilk-nilrebo@ofni

Regional care obligation for psychiatry?

IK number

IK: 261200139

More IK: 261200139

Location number

Location number: 770000000

Old location number: 770000000

Hospital portrait for download