No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Diverse normative Dokumente liegen vor: z.B. GO Klinisches Risikomanagement (12.09.2023)
RM04	Clinical emergency management Diverse normative Dokumente liegen vor: z.B. Reanimation in CPU (28.09.2023)
RM05	Pain management Diverse normative Dokumente liegen vor: z.B. Kardiologische Schmerztherapie (28.09.2023)
RM06	Fall prophylaxis Diverse normative Dokumente liegen vor: z.B. Sturzprotokoll (28.09.2023)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Nachfolgende ST: Dekubitusprophylaxe (28.09.2023)
RM08	Regulated handling of custodial measures Diverse normative Dokumente liegen vor: z.B. Anwendung von freiheitseinschränkenden Maßnahmen (28.09.2023)
RM09	Regulated handling of occurring malfunctions of devices Dienstanweisung und weitere Regelungen liegen vor: Umsetzung MPG MP BetreibV ICME, Umgang mit Medizingeräten und Messmitteln, Meldung Vorkommnis BfMPS (28.09.2023)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Pathologiebesprechungen multimodale klinikinterne 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 Über Sicherheitschecklisten wie z.B. Sicherheits-Checkliste oder Indikationslisten für Transfusionen (28.09.2023)
RM15	Preoperative, complete presentation of necessary findings Spezielle Dokumente der Fachabteilungen wie z.B. KL_Augen_Präoperative Checkliste, Checkliste OP-Dokumentation; Checkliste HT-Dokumentation (28.09.2023)
RM16	Procedure to avoid procedural and patient mix-ups Patientenindentifikationsband (28.09.2023)
RM17	Standards for recovery and postoperative care Postoperativer Patiententransport, GO Interdisziplinäre Versorgung operativer Kinder; Postoperative Schmerztherapie in der Kinderklinik (28.09.2023)
RM18	Discharge management Regelungen zum Entlassmanagement sind im Expertenstandard Entlassmanagement (28.08.2023)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: wöchentlich

Measures

vgl. nachfolgende Punkte

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 15.12.2020
IF03	Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken quartalsweise

No.

Explanation

IF01

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

As of: 15.12.2020

IF03

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

taken quartalsweise

Across all institutions

Conference committee

Conference frequency: andere Frequenz

No.	Explanation
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)