No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available JOS_VA_Risikoüberwachung (25.01.2021)
RM02	Regular further education and training measures
RM04	Clinical emergency management JOS_VA_Notfall (18.03.2022)
RM05	Pain management z.B.Schmerzmanagement in der KKJ und KJPP nach dem Expertenstandard des DNQP (2020); Schmerzmanagement in der Frauenklinik nach dem Expertenstandard des DNQP (2020); Schmerzmanagement im Josefinum nach dem Expertenstandard des DNQP (2020) (17.08.2021)
RM06	Fall prophylaxis JOS_VA_Sturzmanagement; Sturzprophylaxe nach dem Expertenstandard des DNQP (2013) (30.12.2021)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) z.B. Dekubitusprophylaxe und -pflege nach dem Expertenstandard des DNQP (2017), Druckentlastung bei dekubitusgefährdeten Früh- und Neugeborenen so wie bei Dekubitus (23.03.2022)
RM08	Regulated handling of custodial measures KJPP_VA_Fixierungen (02.02.2021)
RM09	Regulated handling of occurring malfunctions of devices JOS_VA_defektes Medizinprodukt (29.06.2020)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen interdisziplinäre 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 WHO Checkliste (02.10.2020)
RM15	Preoperative, complete presentation of necessary findings z.B. KKJ_CL_OP Vorbereitung; FK_CL_OP Grundlage; MKG_CL_Prästationäre Vorbereitung für MKG Patienten (17.06.2020)
RM16	Procedure to avoid procedural and patient mix-ups OP_RL_OP-Statut (17.06.2020)
RM17	Standards for recovery and postoperative care z.B. ANÄ_AA_Postoperative Überwachung im AWR (18.06.2020)
RM18	Discharge management JOS_VA_Entlassmanagement (09.08.2021)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

z.B. Anonymisierte Veröffentlichung von unterwünschten Ereignissen im Mitarbeiterportal, Implementierung des gesetzlichen Entlassmanagements, strukturiertes Risikomanagement mit jährlicher Evaluation klinikbezogener Risiken

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 05.09.2023
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 bei Bedarf

No.

Explanation

IF01

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

As of: 05.09.2023

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 bei Bedarf

Across all institutions

Conference committee

Conference frequency: quartalsweise

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)