No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikorichtlinie Vinzenzkrankenhaus Hannover GmbH (26.04.2019)
RM02	Regular further education and training measures
RM03	Employee surveys
RM05	Pain management Es liegen für die jeweiligen Fachabteilungen SOPs zum Schmerzmanagement vor, beispielsweise: SOP - Standard Perioperative Schmerztherapie Urologie (25.05.2020)
RM06	Fall prophylaxis Prozessbeschreibung zur Umsetzung des an das Vinzenzkrankenhaus angepassten nationalen Expertenstandards-Sturzprophylaxe (24.08.2023)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Prozessbeschreibung zur Umsetzung des an das Vinzenzkrankenhaus angepassten nationalen Expertenstandards Dekubitusprophylaxe (10.08.2020)
RM08	Regulated handling of custodial measures Prozessbeschreibung Fixierung (07.04.2022)
RM09	Regulated handling of occurring malfunctions of devices Begleitheft für Beauftragte MedizinProdukteBetreibV (07.10.2022)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Pathologiebesprechungen
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 OP-Statut (17.05.2022)
RM15	Preoperative, complete presentation of necessary findings OP-Statut (17.05.2022)
RM16	Procedure to avoid procedural and patient mix-ups Patientenidentifikation bei Medikation, Transport, Diagnostik und Behandlung (06.04.2022)
RM17	Standards for recovery and postoperative care SOP – Postoperative Versorgung Aufwachraum (19.01.2019)
RM18	Discharge management Entlassungsstandard (10.06.2022)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Einführung von Patientenarmbändern, Einführung von Checklisten

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 21.07.2022
IF02	Internal evaluation of the received reports taken quartalsweise
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: 21.07.2022

IF02

Internal evaluation of the received reports

taken quartalsweise

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 Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors)