No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (02.02.2016)
RM02	Regular further education and training measures
RM04	Clinical emergency management Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (02.02.2016)
RM05	Pain management Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (02.02.2016)
RM06	Fall prophylaxis Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (02.02.2016)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (02.02.2016)
RM08	Regulated handling of custodial measures Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (02.02.2016)
RM09	Regulated handling of occurring malfunctions of devices Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (02.02.2016)
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 Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (02.02.2015)
RM15	Preoperative, complete presentation of necessary findings Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (02.02.2016)
RM16	Procedure to avoid procedural and patient mix-ups Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (02.02.2016)
RM17	Standards for recovery and postoperative care Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (02.02.2016)
RM18	Discharge management Übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (02.02.2016)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Mitglied im Aktionsbündnis Patientensicherheit Umsetzung der Handlungsempfehlungen des Aktionsbündnisses Patientensicherheit - Sichere Patientenidentifikation (OP-Checkliste, Team time out, Jeder Tupfer zählt) - CIRS Jährliche Pflichtfortbildungen für Ärzte und Pflegekräfte Vierteljährliche Risikobewertung und Berichterstellung CIRS: Analyse, Bewertung und Ableitung von Maßnahmen

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 01.01.2015
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: 01.01.2015

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: halbjährlich

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)