No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Geschäftsordnung (14.05.2020)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Verfahren med. Notfallmanagment (23.07.2020)
RM05	Pain management Standard Schmerztheraphie (01.06.2021)
RM06	Fall prophylaxis Prozessstandard Sturzprävention (27.10.2020)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Prozess-Standard Dekubitus-Prävention (29.07.2020)
RM08	Regulated handling of custodial measures Prozess-Standard Patientenfixierung (15.04.2020)
RM09	Regulated handling of occurring malfunctions of devices MPG-Rechte+Pflichten Geräteanwendung (25.05.2021)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen
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 WHO-Checkliste (21.05.2021)
RM15	Preoperative, complete presentation of necessary findings WHO-checkliste (21.05.2021)
RM16	Procedure to avoid procedural and patient mix-ups WHO-Checkliste (21.05.2021)
RM17	Standards for recovery and postoperative care Standard Op-Nachsorge (07.06.2021)
RM18	Discharge management Prozess Entlassung (27.05.2020)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: jährlich

Measures

Überarbeitung der Behandlungspfade

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 11.05.2020
IF02	Internal evaluation of the received reports taken jährlich
IF03	Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken bei Bedarf

No.

Explanation

IF01

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

As of: 11.05.2020

IF02

Internal evaluation of the received reports

taken jährlich

IF03

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

taken bei Bedarf

Across all institutions

Conference committee

Conference frequency: andere Frequenz

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)