No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Managementbewertung (01.04.2025)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Verfahrensanweisungen der Notaufnahme (Eingriffe, fachfremde Notfälle, Annahme und Übernahme, Patiententransport, Manchester Triage System ect.), Verfahrensanweisungen Schockraum, Reanimationsstandard, Rea-Team, Notfallausrüstung Normalstation/Intensivstation/ZNA, (17.01.2025)
RM05	Pain management Verfahrensanweisung Akutschmerz-Schema (15.03.2025)
RM06	Fall prophylaxis Verfahrensanweisung Sturzprophylaxe (01.04.2025)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Standard zur Dekubitusprophylaxe (03.07.2025)
RM08	Regulated handling of custodial measures Verfahrensanweisung zur Fixierung eines Patienten (19.03.2025)
RM09	Regulated handling of occurring malfunctions of devices Medizinprodukterecht, Umgang mit fehlerhaften Dienstleistungen und mit Korrektur- und Vorbeugungsmaßnahmen (27.04.2023)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Fallbesprechungen zur Analyse von Qualitätsindikatoren
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 Sicherheitscheckliste, Sicherheitscheckliste ambulantes Operieren (02.06.2025)
RM15	Preoperative, complete presentation of necessary findings Dienstanweisung ärztliche Aufklärung (15.03.2025)
RM16	Procedure to avoid procedural and patient mix-ups Risikoarbeitsblatt zur Patientenverwechslung, Verfahrensanweisungen zur Vermeidung von Patientenverwechslung, Verfahrensanweisung zum Umgang mit Patientenidentifikationsarmbändern (10.03.2022)
RM17	Standards for recovery and postoperative care Verfahrensanweisung postoperative Überwachung im Aufwachraum, Verfahrensanweisungen zu postoperativen Versorgung je Abteilung und Intensivmedizinisch (01.04.2025)
RM18	Discharge management Entlassmanagement (22.04.2024)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: andere Frequenz

Measures

Patientenarmband WHO-Checkliste, Seitenmarkierung, Risikoaudit, Manchester Triage, Lerntafeln OneMinuteWonder etc.

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 31.03.2025
IF02	Internal evaluation of the received reports taken monatlich
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: 31.03.2025

IF02

Internal evaluation of the received reports

taken monatlich

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
	Other
EF06	CIRS NRW (North Rhine and Westphalia-Lippe Medical Associations, North Rhine-Westphalia Hospital Association, North Rhine and Westphalia-Lippe Associations of Statutory Health Insurance Physicians, German Medical Association)

No.

Explanation

Other

EF06

CIRS NRW (North Rhine and Westphalia-Lippe Medical Associations, North Rhine-Westphalia Hospital Association, North Rhine and Westphalia-Lippe Associations of Statutory Health Insurance Physicians, German Medical Association)