No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available VA Risikomanagement, VA Dokumentenlenkung (17.04.2025)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management VA Notfallmanagement , IN Notfälle Aushang, Feedback Notfallmanagement, mehrere CL, Basic Life Support VA, ACLS Algorithmus Herzstillstand VA. (05.05.2025)
RM05	Pain management VA Risikomanagement, VA Dokumentenlenkung (17.04.2025)
RM06	Fall prophylaxis VA Risikomanagement, VA Dokumentenlenkung (17.04.2025)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) VA Risikomanagement, VA Dokumentenlenkung (17.04.2025)
RM08	Regulated handling of custodial measures VA Risikomanagement, VA Dokumentenlenkung (17.04.2025)
RM09	Regulated handling of occurring malfunctions of devices MPG Störungsmeldung-Reparaturanforderung VA \| Herr Wissemann (07.09.2023)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen
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 VA Risikomanagement, VA Dokumentenlenkung (17.04.2025)
RM15	Preoperative, complete presentation of necessary findings VA Risikomanagement, VA Dokumentenlenkung (17.04.2025)
RM16	Procedure to avoid procedural and patient mix-ups VA Risikomanagement, VA Dokumentenlenkung (17.04.2025)
RM17	Standards for recovery and postoperative care VA Risikomanagement, VA Dokumentenlenkung (17.04.2025)
RM18	Discharge management Entlassmanagement VA (12.08.2025)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Im Rahmen der internen Qualitätssicherung gibt es ein entsprechendes Meldesystem, dieses lässt auch anonyme Meldungen zu. Es gibt entsprechende Verfahrensanweisungen mit dem Hinweis auf das bundesweite CIRS. Aus diesem bundesweiten Portal werden relevante Meldungen (u.a. Fall des Monats) ausgewertet und in den Leitungsbesprechungen thematisiert.

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 19.08.2024
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: 19.08.2024

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: monatlich

No.	Explanation
EF03	KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association)