No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Managementbewertung (10.05.2023)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Konzept Notfallmanagement, Fortbildungen zum Notfallmanagement, M&M Konferenzen, Prozessbeschreibung (05.04.2023)
RM05	Pain management Manual Schmerzmanagement, Leitlinie Schmerzmanagement und zugehörige Dokumente (12.10.2021)
RM06	Fall prophylaxis Expertenstandard Sturzprophylaxe in der Pflege mit zugehörigen internen Dokumenten (17.07.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Pflegestandard Dekubitusprophylaxe und mitgeltende Dokumente in Anlehnung an den Expertenstandard des Deutschen Netzwerk für Qualitätsentwicklung in der Pflege (09.03.2023)
RM08	Regulated handling of custodial measures Dienstanweisung zur Fixierung von Patienten und mitgeltende Unterlagen (10.02.2023)
RM09	Regulated handling of occurring malfunctions of devices Prozessbeschreibung: Umgang mit defekten Medizinprodukten und mitgeltende Dokumente (08.11.2021)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Mortalitäts- und Morbiditätskonferenzen Pathologiebesprechungen
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 Risikoscreenings OP Verfahren (01.07.2022)
RM15	Preoperative, complete presentation of necessary findings Prozessbeschreibung: Einschleusung in den ZOP (03.05.2022)
RM16	Procedure to avoid procedural and patient mix-ups Umsetzung der Empfehlung vom Aktionsbündnis für Patientensicherheit: Handlungsempfehlungen zur Vermeidung von Eingriffsverwechslungen in der Chirurgie (04.07.2022)
RM17	Standards for recovery and postoperative care Manual Akutschmerztherapie, Nachbehandlungsschemata nach Prozeduren (12.10.2021)
RM18	Discharge management Prozessdarstellung Entlassungsmanagement (22.09.2021)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Prozessoptimierung und Etablierung eines Schleusen PC zur Sicherstellung Patientenidentifikation, Unterlagen vollständig, bereit zur OP

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 12.07.2022
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 monatlich

No.

Explanation

IF01

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

As of: 12.07.2022

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 monatlich

Across all institutions

Conference committee

Conference frequency: monatlich

No.	Explanation
EF01	CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association, National Association of Statutory Health Insurance Doctors)
EF03	KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors)