No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available relevante Dokumentation im digitalen Dokumentenmanagement (01.09.2022)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management relevante Dokumentation im digitalen Dokumentenmanagement (01.09.2022)
RM05	Pain management relevante Dokumentation im digitalen Dokumentenmanagement (01.09.2022)
RM06	Fall prophylaxis relevante Dokumentation im digitalen Dokumentenmanagement (01.09.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) relevante Dokumentation im digitalen Dokumentenmanagement (01.09.2022)
RM08	Regulated handling of custodial measures relevante Dokumentation im digitalen Dokumentenmanagement (01.09.2022)
RM09	Regulated handling of occurring malfunctions of devices relevante Dokumentation im digitalen Dokumentenmanagement (01.09.2022)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Pathologiebesprechungen Palliativbesprechungen Qualitätszirkel
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 relevante Dokumentation im digitalen Dokumentenmanagement (01.09.2022)
RM15	Preoperative, complete presentation of necessary findings relevante Dokumentation im digitalen Dokumentenmanagement (01.09.2022)
RM16	Procedure to avoid procedural and patient mix-ups relevante Dokumentation im digitalen Dokumentenmanagement (01.09.2022)
RM17	Standards for recovery and postoperative care relevante Dokumentation im digitalen Dokumentenmanagement (01.09.2022)
RM18	Discharge management relevante Dokumentation im digitalen Dokumentenmanagement (01.09.2022)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: wöchentlich

Measures

Kontinuierliche Prozessoptimierung im Sinne der Sicherstellung der Patientensicherheit (angelehnt an die Standards der Joint Commission International und den Empfehlungen des Aktionsbündnis Patientensicherheit).

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 01.07.2022
IF02	Internal evaluation of the received reports taken jährlich
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: 01.07.2022

IF02

Internal evaluation of the received reports

taken jährlich

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: wöchentlich

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)