No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Handbuch Qualitätsmanagement (Dok.Nr. 3179)/ Dienstanweisung klinisches Risikomanagement (Dok.Nr. 2799) (29.01.2022)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Handbuch Qualitätsmanagement (Dok.Nr. 3179)/ Dienstanweisung klinisches Risikomanagement (Dok.Nr. 2799) (29.01.2022)
RM05	Pain management Handbuch Qualitätsmanagement (Dok.Nr. 3179)/ Dienstanweisung klinisches Risikomanagement (Dok.Nr. 2799) (29.01.2022)
RM06	Fall prophylaxis Handbuch Qualitätsmanagement (Dok.Nr. 3179)/ Dienstanweisung klinisches Risikomanagement (Dok.Nr. 2799) (29.01.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Handbuch Qualitätsmanagement (Dok.Nr. 3179)/ Dienstanweisung klinisches Risikomanagement (Dok.Nr. 2799) (29.01.2022)
RM08	Regulated handling of custodial measures Handbuch Qualitätsmanagement (Dok.Nr. 3179)/ Dienstanweisung klinisches Risikomanagement (Dok.Nr. 2799) (29.01.2022)
RM09	Regulated handling of occurring malfunctions of devices Handbuch Qualitätsmanagement (Dok.Nr. 3179)/ Dienstanweisung klinisches Risikomanagement (Dok.Nr. 2799) (29.01.2022)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Palliativbesprechungen Qualitätszirkel
RM12	Use of standardised information sheets
RM13	Application of standardised surgical check lists
RM16	Procedure to avoid procedural and patient mix-ups Handbuch Qualitätsmanagement (Dok.Nr. 3179)/ Dienstanweisung klinisches Risikomanagement (Dok.Nr. 2799) (29.01.2022)
RM17	Standards for recovery and postoperative care Handbuch Qualitätsmanagement (Dok.Nr. 3179)/ Dienstanweisung klinisches Risikomanagement (Dok.Nr. 2799) (29.01.2022)
RM18	Discharge management Handbuch Qualitätsmanagement (Dok.Nr. 3179)/ Dienstanweisung klinisches Risikomanagement (Dok.Nr. 2799) (29.01.2022)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: bei Bedarf

Measures

Strukturierte Auswertung von Sturzereignissen und Dekubitusfällen, Aktionen und Organisationsänderungen zur Vermeidung von Medikationsfehlern, Medikationsvisiten der Apotheke und Softwareeinsatz zur Kompatibilitätsprüfung, Einsatz von speziellen Bodenmatten zur Vermeidung von Komplikationen bei Sturzereignissen, Niederflurbetten bei sturzgefährdeten Patienten, Auswertung von CIRS, Gewalt-, Hinweisgeber-Fällen aus eigenem KH und KH-CIRS-Netz-Deutschland

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 24.05.2023
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 quartalsweise

No.

Explanation

IF01

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

As of: 24.05.2023

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 quartalsweise

Across all institutions

Conference committee

Conference frequency: bei Bedarf

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)