No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Dokumentenmanagementsystem (29.09.2020)
RM02	Regular further education and training measures
RM04	Clinical emergency management Dokumentenmanagementsystem (29.09.2020)
RM05	Pain management Dokumentenmanagementsystem (29.09.2020)
RM06	Fall prophylaxis Dokumentenmanagementsystem (29.09.2020)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dokumentenmanagementsystem (29.09.2020)
RM08	Regulated handling of custodial measures Dokumentenmanagementsystem (29.09.2020)
RM09	Regulated handling of occurring malfunctions of devices Dokumentenmanagementsystem (29.09.2020)
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
RM15	Preoperative, complete presentation of necessary findings Dokumentenmanagementsystem (29.09.2020)
RM16	Procedure to avoid procedural and patient mix-ups Dokumentenmanagementsystem (29.09.2020)
RM17	Standards for recovery and postoperative care Dokumentenmanagementsystem (29.09.2020)
RM18	Discharge management Dokumentenmanagementsystem (29.09.2020)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Aus CIRS-Meldungen, Feedback der Patienten / Angehörigen, Begehungen, Befragungen werden Maßnahmen abgeleitet, die zur Patientensicherheit beitragen, z. B. Verbesserung der Lesbarkeit von Dokumentation, Checklisten, Schulungen. Mittels einem hohen Einsatz von Fachkräften, standardisierter Prozeduren, Checklisten und gegenseitiger kollegialer Kontrolle erfolgt die tägliche Arbeit auf einem hohen sicherheitstechnischen Niveau.

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 06.07.2021
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: 06.07.2021

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: monatlich

No.	Explanation
EF01	CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association, National Association of Statutory Health Insurance Doctors)
EF03	KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors)