No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available CIRS (Critical Incident Reporting System) im Klinikum Westmünsterland (15.12.2021)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management CIRS (Critical Incident Reporting System) im Klinikum Westmünsterland (15.12.2021)
RM05	Pain management CIRS (Critical Incident Reporting System) im Klinikum Westmünsterland (15.12.2021)
RM06	Fall prophylaxis CIRS (Critical Incident Reporting System) im Klinikum Westmünsterland (15.12.2021)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) CIRS (Critical Incident Reporting System) im Klinikum Westmünsterland (15.12.2021)
RM08	Regulated handling of custodial measures CIRS (Critical Incident Reporting System) im Klinikum Westmünsterland (15.12.2021)
RM09	Regulated handling of occurring malfunctions of devices CIRS (Critical Incident Reporting System) im Klinikum Westmünsterland (15.12.2021)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen interdisziplinäre Fallbesprechungen im Rahmen von Zentren
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 CIRS (Critical Incident Reporting System) im Klinikum Westmünsterland (15.12.2021)
RM15	Preoperative, complete presentation of necessary findings CIRS (Critical Incident Reporting System) im Klinikum Westmünsterland (15.12.2021)
RM16	Procedure to avoid procedural and patient mix-ups CIRS (Critical Incident Reporting System) im Klinikum Westmünsterland (15.12.2021)
RM17	Standards for recovery and postoperative care CIRS (Critical Incident Reporting System) im Klinikum Westmünsterland (15.12.2021)
RM18	Discharge management CIRS (Critical Incident Reporting System) im Klinikum Westmünsterland (15.12.2021)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: andere Frequenz

Measures

- Tagungsfrequenz des Gremiums alle 8 Wochen - Anwendung von Patientenidentifikationsarmbändern - Anwendung der WHO- Sicherheitscheckliste präoperativ/ intraoperativ - Maßnahmen zur Arzneimitteltherapiesicherheit - Präsentation der Quick- Alerts im Intranet - Risikoaudits durch die Apotheke - Maßnahmenableitungen aus Befragungen (Mitarbeiter, Einweiser, Patienten) - Beschwerdemanagement - Einführung einer Endoskopie- und Herzkatheterlaborsicherheitscheckliste - Auswertung externer QS

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 31.12.2021
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: 31.12.2021

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)