No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitäts- u. klinisches Risikomanagement Handbuch "Zentrale Prozesse" Version 21.0 (06.03.2023)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Qualitäts- u. klinisches Risikomanagement Handbuch "Zentrale Prozesse" Version 21.0 (06.03.2023)
RM05	Pain management Qualitäts- u. klinisches Risikomanagement Handbuch "Zentrale Prozesse" Version 21.0 (06.03.2023)
RM06	Fall prophylaxis Qualitäts- u. klinisches Risikomanagement Handbuch "Zentrale Prozesse" Version 21.0 (06.03.2023)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Qualitäts- u. klinisches Risikomanagement Handbuch "Zentrale Prozesse" Version 21.0 (06.03.2023)
RM08	Regulated handling of custodial measures QM-VA_MP11_Freiheitsentziehende Maßnahmen (31.08.2021)
RM09	Regulated handling of occurring malfunctions of devices Qualitäts- u. klinisches Risikomanagement Handbuch "Zentrale Prozesse" Version 21.0 (06.03.2023)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Pathologiebesprechungen Palliativbesprechungen Qualitätszirkel Perinatalkonferenzen
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 QM_VA_MP14_Patientensicherheit u. OP-Checkliste (24.04.2019)
RM15	Preoperative, complete presentation of necessary findings QM_VA_MP14_Patientensicherheit u. OP-Checkliste (24.04.2019)
RM16	Procedure to avoid procedural and patient mix-ups QM_VA_MP13_Team-TimeOut u. ZählkontrollenQM_VA_MP14_PatientensicherheitQM_VA_MP16_Patienten-ID-Bänder (24.10.2022)
RM17	Standards for recovery and postoperative care Qualitäts- u. klinisches Risikomanagement Handbuch "Zentrale Prozesse" Version 21.0 (06.03.2023)
RM18	Discharge management Qualitäts- u. klinisches Risikomanagement Handbuch "Zentrale Prozesse" Version 21.0 (06.03.2023)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

z. B.: SOP zur Vermeidung von Seitenverwechselungen, Überarbeitung von OP-Checklisten, Patientenidentifikationsbändern; standardisierte Etikettierung von Spritzen; gesonderte Applikations-Systeme zur Vermeidung von Verwechselungen bei der enteralen bzw. parenteralen Medikamentengabe.

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 30.05.2022
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 bei Bedarf

No.

Explanation

IF01

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

As of: 30.05.2022

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 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)
EF06	CIRS NRW (North Rhine and Westphalia-Lippe Medical Chambers, North Rhine Westphalia Hospital Association, North Rhine and Westphalia-Lippe Association of Statutory Health Insurance Doctors, German Medical Association, National Association of Statutory Hea