No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualität und Patientensicherheit - Strategie 2.0 (10.02.2022)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management STJ hausinterner medizinischer Notfall (13.06.2024)
RM05	Pain management KPJ Management der Akutschmerztherapie (08.08.2023)
RM06	Fall prophylaxis KPJ Sturzrisikoerkennung, Sturzvermeidung und Sturzdokumentation (27.01.2025)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) KPJ Dekubitus-Risiko-Erkennung und Dekubitusvermeidung (20.02.2025)
RM08	Regulated handling of custodial measures KAJ Umgang mit freiheitsentziehenden Maßnahmen (25.10.2022)
RM09	Regulated handling of occurring malfunctions of devices KPJ Vorgehen im Falle eines Vorkommnis durch ein Medizinprodukt (20.10.2025)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Pathologiebesprechungen Palliativbesprechungen ad hoc Fallbesprechungen Ethische Fallbesprechungen
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 KPJ OP Sicherheitscheckliste (20.10.2025)
RM15	Preoperative, complete presentation of necessary findings KPJ Präoperative Patientenvorbereitung auf Normal- und Intensivstation (28.10.2024)
RM16	Procedure to avoid procedural and patient mix-ups KAJ Patientenarmbänder (06.09.2022)
RM17	Standards for recovery and postoperative care KPJ Postoperative Therapie im Aufwachraum (01.09.2025)
RM18	Discharge management KPJ Ablauf Sozialdienst - Flussdiagramm (24.09.2025)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

kontinuierliche Verbesserungen der Prozesse

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 13.01.2023
IF02	Internal evaluation of the received reports taken monatlich
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: 13.01.2023

IF02

Internal evaluation of the received reports

taken monatlich

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
	Other
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)
EF13	DokuPIK (Documentation of Pharmaceutical Interventions in Hospitals at the Federal Association of German Hospital Pharmacists (ADKA)

No.

Explanation

Other

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)

EF13

DokuPIK (Documentation of Pharmaceutical Interventions in Hospitals at the Federal Association of German Hospital Pharmacists (ADKA)