No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Digitales Dokumentenlenkungsmanagement, Auditmanagement, Maßnahmenmanagement und Feedbackmanagement (23.06.2025)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Digitales Dokumentenlenkungsmanagement, Auditmanagement, Maßnahmenmanagement und Feedbackmanagement (23.06.2025)
RM05	Pain management Digitales Dokumentenlenkungsmanagement, Auditmanagement, Maßnahmenmanagement und Feedbackmanagement (23.06.2025)
RM06	Fall prophylaxis Digitales Dokumentenlenkungsmanagement, Auditmanagement, Maßnahmenmanagement und Feedbackmanagement (23.06.2025)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Digitales Dokumentenlenkungsmanagement, Auditmanagement, Maßnahmenmanagement und Feedbackmanagement (23.06.2025)
RM08	Regulated handling of custodial measures Digitales Dokumentenlenkungsmanagement, Auditmanagement, Maßnahmenmanagement und Feedbackmanagement (23.06.2025)
RM09	Regulated handling of occurring malfunctions of devices Digitales Dokumentenlenkungsmanagement, Auditmanagement, Maßnahmenmanagement und Feedbackmanagement (23.06.2025)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen
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 Digitales Dokumentenlenkungsmanagement, Auditmanagement, Maßnahmenmanagement und Feedbackmanagement (23.06.2025)
RM15	Preoperative, complete presentation of necessary findings Digitales Dokumentenlenkungsmanagement, Auditmanagement, Maßnahmenmanagement und Feedbackmanagement (23.06.2025)
RM16	Procedure to avoid procedural and patient mix-ups Digitales Dokumentenlenkungsmanagement, Auditmanagement, Maßnahmenmanagement und Feedbackmanagement (23.06.2025)
RM17	Standards for recovery and postoperative care Digitales Dokumentenlenkungsmanagement, Auditmanagement, Maßnahmenmanagement und Feedbackmanagement (23.06.2025)
RM18	Discharge management Digitales Dokumentenlenkungsmanagement, Auditmanagement, Maßnahmenmanagement und Feedbackmanagement (23.06.2025)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: quartalsweise

Measures

Wir nutzen in unserem Krankenhaus ein CIRS Fehlermeldesystem. In diesem Programm hat jeder Mitarbeiter die Möglichkeit potenzielle oder bestehende risikobehaftete Ereignisse anonym zu melden. Die Auswertung und weitere Bearbeitung erfolgt durch das CIRS Auswerterteam, welches berufsgruppenübergreifend zusemmengesetzt ist (Ärzte, Mitarbeiter aus der Pflege und Verwaltung).

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 16.08.2024
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: 16.08.2024

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: quartalsweise

No.	Explanation
EF06	CIRS NRW (North Rhine and Westphalia-Lippe Medical Associations, North Rhine-Westphalia Hospital Association, North Rhine and Westphalia-Lippe Associations of Statutory Health Insurance Physicians, German Medical Association)