No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Diverse normative Dokumente liegen vor: z.B. GO Klinisches Risikomanagement (14.12.2020)
RM04	Clinical emergency management Diverse normative Dokumente liegen vor: z.B. -KL_MB Reanimation in CPU-180628_REV1 (06.07.2018)
RM05	Pain management Diverse normative Dokumente liegen vor: z.B. MK-KL-ST Kardiologische Schmerztherapie-160628-REV1 (04.03.2015)
RM06	Fall prophylaxis Diverse normative Dokumente liegen vor: z.B. MK_KL_ST_Sturzprotokoll_121122_Rev2.pdf (22.11.2012)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Nachfolgende ST: KL_PD_ST_Dekubitusprophylaxe_151201_REV2 (01.12.2015)
RM08	Regulated handling of custodial measures Diverse normative Dokumente liegen vor: z.B. MK_MK_ST_Anwendung von freiheitseinschränkenden Maßnahmen_130917_Rev1.pdf (17.09.2013)
RM09	Regulated handling of occurring malfunctions of devices Dienstanweisung und weitere Regelungen liegen vor: MK-MK-DA Umsetzung MPG MP BetreibV ICME_180906-REV2, MK-QM-F Umgang mit Medizingeräten und Messmitteln _111116 MK_MK_F_Meldung Vorkommnis BfMPS_180904_Rev1.d (04.09.2018)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Pathologiebesprechungen multimodale klinikinterne Fallbesprechungen
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 Über Sicherheitschecklisten wie z.B. KL_Chir_F_Sicherheits Checkliste_100317_Rev5.doc oder Indikationslisten für Transfusionen 2016-11-07 (07.11.2016)
RM15	Preoperative, complete presentation of necessary findings Spezielle Dokumente der Fachabteilungen wie z.B. KL_Augen_Präoperative Checkliste_Rev2_160330, Checkliste OP-Dokumentation_Rev1_180524; Checkliste_HT-Dokumentation_Rev1_180226 (26.06.2019)
RM16	Procedure to avoid procedural and patient mix-ups MK-MK-AA Patientenindentifikationsband-161005 REV1 (05.10.2016)
RM17	Standards for recovery and postoperative care MK_KL_ST_Postoperativer Patiententransport_090707_Rev1.pdf MK_KL_GO_Interdisziplinäre Versorgung operativer Kinder_20201202_Rev3.pdf KL_Kikli_MB_Postoperative Schmerztherapie in der Kinderklinik_131108_Rev1.pdf (02.12.2020)
RM18	Discharge management Regelungen zum Entlassmanagement sind im Handbuch Casemanagement festgelegt: Handbuch_CM_2008.pdf ; MK_PD_ST_Expertenstandard Entlassmanagement_190924_Rev2 MK_Zapo_SOP_Entlassmanagement Apotheke_190412_Rev1 (24.09.2019)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: wöchentlich

Measures

vgl. nachfolgende Punkte

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 14.12.2020
IF03	Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken quartalsweise

No.

Explanation

IF01

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

As of: 14.12.2020

IF03

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

taken quartalsweise

Across all institutions

Conference committee

Conference frequency: andere Frequenz

No.	Explanation
EF06	CIRS NRW (North Rhine and Westphalia-Lippe Medical Chambers, North Rhine Westphalia Hospital Association, North Rhine and Westphalia-Lippe Association of Statutory Health Insurance Doctors, German Medical Association, National Association of Statutory Hea