No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Konzept Risikomanagement (10.03.2020)
RM02	Regular further education and training measures
RM04	Clinical emergency management Polytrauma Notfälle mit vitaler Bedrohung Notfälle ohne vitale Bedrohung Verantwortlichkeiten vitale Bedrohung mit Alarmierungsliste (05.09.2023)
RM05	Pain management Manual Schmerztherapie (08.09.2023)
RM06	Fall prophylaxis Pflegestandard Sturzprophylaxe Sturzprotokoll (06.01.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Prozessablauf Dekubitus Dokumentationsbogen Dekubitus Arbeitsanweisung Dekubitusprophylaxe Dekubitus in der ZNA (23.08.2021)
RM08	Regulated handling of custodial measures Umgang mit Fixierungen Ärztliche Anordnung und Durchführung von Fixierungen (29.11.2022)
RM09	Regulated handling of occurring malfunctions of devices Konzept Risikomanagement (10.03.2020)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Palliativbesprechungen
RM12	Use of standardised information sheets
RM13	Application of standardised surgical check lists
RM14	Preoperative summary of predictable critical surgical steps, surgical time and expected blood loss Team Time Out (27.01.2020)
RM15	Preoperative, complete presentation of necessary findings Team Time Out (27.01.2020)
RM16	Procedure to avoid procedural and patient mix-ups Checkliste zur Vermeidung von Eingriffsverwechslungen (10.07.2019)
RM17	Standards for recovery and postoperative care Protokoll Aufwachraum Pflegestandard OP/Anästhesie OP-Satzung (01.09.2019)
RM18	Discharge management VA Entlassungsmanagement (07.10.2022)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: quartalsweise

Measures

Eingesetztes System: CIRS EKSM Erhöhung der Patientensicherheit beim Umgang mit Medikamenten Vermeidung von Eingriffsverwechslungen mehrfache Kontrolle der Patientenidentität

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 18.08.2020
IF02	Internal evaluation of the received reports taken quartalsweise
IF03	Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken jährlich

No.

Explanation

IF01

Documentation and procedural instructions for handling the error reporting system are available

As of: 18.08.2020

IF02

Internal evaluation of the received reports

taken quartalsweise

IF03

Training of employees in handling the error reporting system and in implementing the findings from the error reporting system

taken jährlich

Across all institutions

Conference committee

Conference frequency: bei Bedarf

No.	Explanation
EF03	KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors)