No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risiko- und Chancenmanagement (21.08.2023)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Reanimationsrichtlinie u. Management Innerklinischer Notfälle (28.03.2023)
RM05	Pain management Schmerzmanagement im HEH u. abteilungsbezogene Vorgabedokumente (03.01.2022)
RM06	Fall prophylaxis Pflegestandard Sturzprophylaxe (14.01.2023)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Pflegestandard Dekubitusprophylaxe (24.04.2023)
RM08	Regulated handling of custodial measures Ruhigstellung und Sedierung (25.10.2023)
RM09	Regulated handling of occurring malfunctions of devices Umgang mit Fehlfunktionen bzw. Defekten von Geräten (28.07.2023)
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 OP-Sicherheitscheckliste (22.08.2023)
RM15	Preoperative, complete presentation of necessary findings Umgang mit der OP-Sicherheitscheckliste (18.04.2023)
RM16	Procedure to avoid procedural and patient mix-ups Umgang mit der OP-Sicherheitscheckliste (18.04.2023)
RM17	Standards for recovery and postoperative care Postoperative Überwachung auf Station, Überwachung auf Intensiv-Station, Anästhesieüberwachung Aufwachraum (19.10.2023)
RM18	Discharge management Entlassung, Pflegeinformation Entlassung (17.02.2022)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: quartalsweise

Measures

Änderung der OP-Sicherheitscheckliste und Endoskopie-Checkliste

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 08.03.2022
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 halbjährlich

No.

Explanation

IF01

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

As of: 08.03.2022

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 halbjährlich

Across all institutions

Conference committee

Conference frequency: quartalsweise

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)