No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QRM VA Handbuch Risikomanagement / VA Dokumentenlenkung (23.01.2023)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management KD DA Alarm- und Einsatzplan (Abschnitt A, Abschnitt BI, Abschnitt BII, Abschnitt C, Anhang Alarmierungslisten, Anhang Auftragsblätter) (09.02.2023)
RM05	Pain management ANÄ VA Postoperative Schmerzen auf Station (20.06.2022)
RM06	Fall prophylaxis PD PS Expertenstandard Sturz (15.11.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) PD PS 13 Dekubitusprophylaxe (08.05.2023)
RM08	Regulated handling of custodial measures QRM VA Freiheitsentziehende Maßnahmen (29.12.2022)
RM09	Regulated handling of occurring malfunctions of devices MPMT DA Medizinprodukte: Errichten, Instandhalten, Betreiben, Anwenden; MPMT VA Regelung der Zuständigkeiten bei Medizinprodukten; VS DA Strahlenschutzanweisungen (08.02.2023)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen 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 KD DA OP-Statut; AED VA Vermeidung von Eingriffsverwechslungen (06.06.2023)
RM15	Preoperative, complete presentation of necessary findings KD DA OP-Statut; AED VA Vermeidung von Eingriffsverwechslungen (06.06.2023)
RM16	Procedure to avoid procedural and patient mix-ups PD CL Prävention von Eingriffsverwechslungen; AED VA Vermeidung von Eingriffsverwechslungen (26.04.2022)
RM17	Standards for recovery and postoperative care ANÄ VA Organisation des Aufwachraumes (20.06.2022)
RM18	Discharge management EM VA Entlassmanagement (22.06.2023)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: quartalsweise

Measures

Prüfung ggf. Anpassung der SOPs; Veröffentlichung bzw. Schulung der Maßnahmen zur Verbesserung der Patientensicherheit; Regelmäßige Auswertungen; Verhaltensänderungen

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 04.07.2023
IF02	Internal evaluation of the received reports taken halbjährlich
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: 04.07.2023

IF02

Internal evaluation of the received reports

taken halbjährlich

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)