No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitätsmanagement-Dokumentation , QMH Version 7.6, elektron. Dokumentation im Dokumentenmanagementsystem (05.01.2024)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Alarm- und Einsatzplan (01.07.2021)
RM05	Pain management Qualitätsmanagement-Dokumentation , QMH Version 7.6, elektron. Dokumentation im Dokumentenmanagementsystem (05.01.2024)
RM06	Fall prophylaxis Assessment Sturz, Leitlinie Sturzprophylaxe, VA Sturzprävention (22.02.2024)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Leitlinie Dekubitusprohylaxe (22.02.2024)
RM08	Regulated handling of custodial measures Qualitätsmanagement-Dokumentation , QMH Version 7.6, elektron. Dokumentation im Dokumentenmanagementsystem (05.01.2024)
RM09	Regulated handling of occurring malfunctions of devices Qualitätsmanagement-Dokumentation , QMH Version 7.6, elektron. Dokumentation im Dokumentenmanagementsystem (05.01.2024)
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
RM14	Preoperative summary of predictable critical surgical steps, surgical time and expected blood loss Qualitätsmanagement-Dokumentation , QMH Version 7.6, elektron. Dokumentation im Dokumentenmanagementsystem (05.01.2024)
RM15	Preoperative, complete presentation of necessary findings Qualitätsmanagement-Dokumentation , QMH Version 7.6, elektron. Dokumentation im Dokumentenmanagementsystem (05.01.2024)
RM16	Procedure to avoid procedural and patient mix-ups Qualitätsmanagement-Dokumentation , QMH Version 7.6, elektron. Dokumentation im Dokumentenmanagementsystem (05.01.2024)
RM17	Standards for recovery and postoperative care Qualitätsmanagement-Dokumentation , QMH Version 7.6, elektron. Dokumentation im Dokumentenmanagementsystem (05.01.2024)
RM18	Discharge management Qualitätsmanagement-Dokumentation , QMH Version 7.6, elektron. Dokumentation im Dokumentenmanagementsystem (05.01.2024)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: bei Bedarf

Measures

Fallberichte im hausinternen Intranet inkl. Risikobewertung und Maßnahmenableitung, Informationen für Mitarbeiter zum Thema CIRS und Schulungsangebote.

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 20.11.2021
IF02	Internal evaluation of the received reports taken jährlich
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: 20.11.2021

IF02

Internal evaluation of the received reports

taken jährlich

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: bei Bedarf

No.	Explanation
EF01	CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association)
EF03	KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association)
EF13	DokuPIK (Documentation of Pharmaceutical Interventions in Hospitals at the Federal Association of German Hospital Pharmacists (ADKA)