No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitätsmanagement-Konzept, Risikomanagement-Konzept (29.11.2022)
RM02	Regular further education and training measures
RM04	Clinical emergency management OP-Statut; SOP Reanimation (13.06.2023)
RM05	Pain management u. a. Leitlinie "Handlungs-/Therapieempfehlung Schmerztherapie" (02.06.2022)
RM06	Fall prophylaxis Standard "Sturzprophylaxe" (20.03.2023)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Risikoerfassung anhand der Braden-Skala - Prophylaxe im Rahmen der Interventionserfassung (05.05.2023)
RM08	Regulated handling of custodial measures Standard "Umgang mit freiheitsentziehenden Maßnahmen (FEM)/Fixierungen" (27.12.2022)
RM09	Regulated handling of occurring malfunctions of devices Qualitätsmanagement-Konzept, Risikomanagement-Konzept (29.11.2022)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Palliativbesprechungen Komplikationsbesprechungen
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 Sicherheitscheckliste OP-Saal (18.07.2023)
RM15	Preoperative, complete presentation of necessary findings Sicherheitscheckliste OP-Saal (18.07.2023)
RM16	Procedure to avoid procedural and patient mix-ups Sicherheitscheckliste OP-Saal (18.07.2023)
RM17	Standards for recovery and postoperative care Prozessbeschreibung "Intensivtherapie" (16.06.2023)
RM18	Discharge management Prozessbeschreibung "Entlassung - Ärztlicher Dienst"; Patienteninformation Entlassmangement (29.08.2023)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: bei Bedarf

Measures

Korrektur- und Vorbeugemaßnahmen werden bei Bedarf umgesetzt

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 04.10.2022
IF02	Internal evaluation of the received reports taken bei Bedarf
IF03	Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken jährlich

No.

Explanation

IF01

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

As of: 04.10.2022

IF02

Internal evaluation of the received reports

taken bei Bedarf

IF03

Training of employees in handling the error reporting system and in implementing the findings from the error reporting system

taken jährlich

Across all institutions

Conference committee

Conference frequency: andere Frequenz

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)