No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Geschäftsordnung Risikomanagement (06.07.2023)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Geschäftsordnung Risikomanagement und z.B. Arbeitsanweisung Notfallmanagement HKL (23.05.2022)
RM05	Pain management Geschäftsordnung Risikomanagement und Arbeitsanweisung Schmerzmanagement (07.12.2022)
RM06	Fall prophylaxis Geschäftsordnung Risikomanagement und Standard Sturzprophylaxe (06.12.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Geschäftsordnung Risikomanagement und Standard Dekubitusprophylaxe (06.12.2022)
RM08	Regulated handling of custodial measures Geschäftsordnung Risikomanagement und z.B. Verfahrensanweisung Rechtliche Grundlagen und besondere Situationen zu freiheitsentziehen Maßnahmen (26.03.2022)
RM09	Regulated handling of occurring malfunctions of devices Geschäftsordnung Risikomanagement und z. B. Verfahrensanweisung Fehlermeldung in der Radiologie (12.12.2022)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Palliativbesprechungen
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 Geschäftsordnung Risikomanagement und WHO-Checkliste (28.02.2022)
RM15	Preoperative, complete presentation of necessary findings Geschäftsordnung Risikomanagement und z.B. Checkliste "Prästationär/Prä-OP" (08.03.2021)
RM16	Procedure to avoid procedural and patient mix-ups Geschäftsordnung Risikomanagement und z.B. Verfahrensanweisung Sicherheits-Check vor operativen Eingriffen (06.12.2022)
RM17	Standards for recovery and postoperative care Geschäftsordnung Risikomanagement und z.B. Verfahrensanweisung Postoperative Versorgung von Patienten mit Darmkrebs (28.06.2021)
RM18	Discharge management Geschäftsordnung Risikomanagement und Verfahrensanweisung Entlassmanagement (30.04.2021)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Prozessanpassungen, Schulungen

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 07.03.2022
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: 07.03.2022

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)