No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Interne Audits am KSM - Regelmäßig stattfindende interne Audits werden im Programm Anaquestra dokumentiert und ggf. Maßnahmenlisten generiert und die Abarbeitung der Maßnahmen verfolgt. (29.03.2022)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Reanimation bei Kreislaufstillstand ReaTeam (31.08.2022)
RM05	Pain management Schmerzmanagement Algorithmus (13.10.2021)
RM06	Fall prophylaxis Sturzprophylaxe Pflegestandard (21.12.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusprophylaxe nach Expertenstandard (11.03.2022)
RM08	Regulated handling of custodial measures Standard Fixierungen und Alternativen (03.05.2021)
RM09	Regulated handling of occurring malfunctions of devices Dienstanweisung zu MPG und MPBetreibV (Medizintechnik) (30.03.2022)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Palliativbesprechungen Leitungszirkel Perinatalkonferenzen
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 OP-Checkliste (31.05.2022)
RM15	Preoperative, complete presentation of necessary findings Voruntersuchungen zur Narkose (15.07.2021)
RM16	Procedure to avoid procedural and patient mix-ups Verfahrensanweisung Patientenidentifikationsarmbänder (22.11.2021)
RM17	Standards for recovery and postoperative care Standard zur postoperativen pflegerischen Versorgung des Patienten (12.08.2020)
RM18	Discharge management Verfahrensanweisung Entlassmanagement (07.10.2022)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: quartalsweise

Measures

diverse

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 02.08.2021
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 monatlich

No.

Explanation

IF01

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

As of: 02.08.2021

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 monatlich

Across all institutions

Conference committee

Conference frequency: quartalsweise

No.	Explanation
	Other
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)

No.

Explanation

Other

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)