No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Wirksamkeitsverfolgung von Vorbeuge- u. Korrekturmaßnahmen (24.03.2024)
RM02	Regular further education and training measures
RM04	Clinical emergency management AB-033 Medizinischer Notfall, Standards, Checklisten, Schockraumregelungen, REA-Team, Notfallausrüstung (Koffer, Wagen, Rucksack). (08.08.2023)
RM05	Pain management DO-17266 Konzept Schmerztherapie, Schmerzdokumentationen, Expertenstandards und Postoperative Schmerztherapie AWR (02.05.2023)
RM06	Fall prophylaxis Sturzprophylaxe basierend auf den nationalen Expertenstandard "Sturzprophylaxe in der Pflege" (05.06.2024)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusprophylaxe u. Behandlung basierend auf den nationalen Expertenstandard "Dekubitusprophylaxe in der Pflege" (17.04.2024)
RM08	Regulated handling of custodial measures Verfahrensanweisung Anregung von Betreuungseilmaßnahmen (16.06.2023)
RM09	Regulated handling of occurring malfunctions of devices AB-101 Überwachung und Messung (24.05.2023)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen 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 OP-Statut (05.06.2024)
RM15	Preoperative, complete presentation of necessary findings OP-Statut (05.06.2024)
RM16	Procedure to avoid procedural and patient mix-ups Perioperative Sicherheitscheckliste (06.02.2024)
RM17	Standards for recovery and postoperative care Verfahrensanweisung Versorgung der Patienten im Aufwachraum (18.07.2022)
RM18	Discharge management Verfahrensanweisung Zentrales Entlassmanagement (30.05.2023)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: bei Bedarf

Measures

Zur Optimierung der Patientensicherheit haben wir eine perioperative Sicherheitscheckliste, weitere OP-Checklisten und Patientenidentifikationsarmbänder etc. eingeführt. 2024 überarbeiteten wir das OP-Statut.

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 14.03.2023
IF02	Internal evaluation of the received reports taken bei Bedarf
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: 14.03.2023

IF02

Internal evaluation of the received reports

taken bei Bedarf

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
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)