No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available i.R. Gesamthauszertifizierung nach DIN EN ISO 9001:2015 (24.04.2022)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management i.R. Gesamthauszertifizierung nach DIN EN ISO 9001:2015 (24.04.2022)
RM05	Pain management i.R. Gesamthauszertifizierung nach DIN EN ISO 9001:2015 (24.04.2022)
RM06	Fall prophylaxis i.R. Gesamthauszertifizierung nach DIN EN ISO 9001:2015 (24.04.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) i.R. Gesamthauszertifizierung nach DIN EN ISO 9001:2015 (24.04.2022)
RM08	Regulated handling of custodial measures i.R. Gesamthauszertifizierung nach DIN EN ISO 9001:2015 (24.04.2022)
RM09	Regulated handling of occurring malfunctions of devices i.R. Gesamthauszertifizierung nach DIN EN ISO 9001:2015 (24.04.2022)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Pathologiebesprechungen Palliativbesprechungen
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 i.R. Gesamthauszertifizierung nach DIN EN ISO 9001:2015 (24.04.2022)
RM15	Preoperative, complete presentation of necessary findings i.R. Gesamthauszertifizierung nach DIN EN ISO 9001:2015 (24.04.2022)
RM16	Procedure to avoid procedural and patient mix-ups i.R. Gesamthauszertifizierung nach DIN EN ISO 9001:2015 (24.04.2022)
RM17	Standards for recovery and postoperative care i.R. Gesamthauszertifizierung nach DIN EN ISO 9001:2015 (24.04.2022)
RM18	Discharge management i.R. Gesamthauszertifizierung nach DIN EN ISO 9001:2015 (24.04.2022)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: andere Frequenz

Measures

Patientenidentifikationsarmbänder, ALS-Schulungen, Simulationstraining, Regelmäßige Überarbeitung der OP-Checklisten, OP-Seitenmarkierung

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 09.01.2023
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: 09.01.2023

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: andere Frequenz

No.	Explanation
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)