No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM-Organisationshandbuch (20.07.2023)
RM02	Regular further education and training measures
RM04	Clinical emergency management QM-Organisationshandbuch (20.07.2023)
RM05	Pain management QM-Organisationshandbuch (20.07.2023)
RM06	Fall prophylaxis QM-Organisationshandbuch (20.07.2023)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) QM-Organisationshandbuch (20.07.2023)
RM08	Regulated handling of custodial measures QM-Organisationshandbuch (20.07.2023)
RM09	Regulated handling of occurring malfunctions of devices QM-Organisationshandbuch (20.07.2023)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Pathologiebesprechungen Palliativbesprechungen Abteilungsübergreifende interdisziplinäre Fallbesprechungen bei besonderen Vorkommnissen interdisziplinäre Fallkonferenzen in allen Abteilungen z. B. Perinatalkonferenzen Fallsupervisionen in der KJP
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 QM-Organisationshandbuch (20.07.2023)
RM15	Preoperative, complete presentation of necessary findings QM-Organisationshandbuch (20.07.2023)
RM16	Procedure to avoid procedural and patient mix-ups QM-Organisationshandbuch (20.07.2023)
RM17	Standards for recovery and postoperative care QM-Organisationshandbuch (20.07.2023)
RM18	Discharge management QM-Organisationshandbuch (20.07.2023)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Entsprechend der jeweiligen Fälle

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 20.07.2023
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 monatlich

No.

Explanation

IF01

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

As of: 20.07.2023

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 monatlich

Across all institutions

Conference committee

Conference frequency: monatlich

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)