No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available "Systemhandbuch Qualitäts- und Risikomanagement der DRK Trägergesellschaft Süd-West mbH" (fortlaufende Aktualisierung der Einzelkapitel und -Dokumente, Sonderdruck Gesamtausgabe Vers. 7 vom 17.11.2020); Richtlinie zum Klinischen Risikomanagement Vers. 3 vom 01.12.2022 (01.12.2022)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Verfahrensanweisung (VA) Notfallaufnahme- und Behandlung, VA Notfallmanagement (12.10.2022)
RM05	Pain management VA Schmerzmanagement (10.11.2020)
RM06	Fall prophylaxis VA Umgang mit Stürzen (20.01.2023)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) VA Dekubitusmanagement (08.12.2023)
RM08	Regulated handling of custodial measures VA Freiheitsentziehende Maßnahmen (10.11.2020)
RM09	Regulated handling of occurring malfunctions of devices Organisationshandbuch Medizintechnik (20.03.2023)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Mortalitäts- und Morbiditätskonferenzen Palliativbesprechungen Röntgenbesprechung Perinatalkonferenz
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 Standards Prä- und Post OP aller Fachabteilungen (Allgemein- und Viszeralchirurgie, Gefäßchirurgie, Unfallchirurgie, Gynäkologie/Geburtshilfe und Urologie) (15.12.2020)
RM15	Preoperative, complete presentation of necessary findings AA Umgang mit Befunden und Fremdbefunden (23.02.2023)
RM16	Procedure to avoid procedural and patient mix-ups Arbeitsanweisung (AA) Maßnahmen zur Vermeidung von OP-Verwechslungen (01.08.2024)
RM17	Standards for recovery and postoperative care Med. Standard (STD) Post-Op Überwachung (AWR) (01.08.2024)
RM18	Discharge management VA Entlassung (16.06.2023)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Erstellung und Überarbeitung von Verfahrensanweisungen, Arbeitsanweisungen und Standards. Verbesserungen in Ablauforganisation und Personalsituation, Einrichtung einer unabhängigen Stabsstelle "OP-Koordinator" bei der Krankenhausleitung.

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 08.04.2020
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: 08.04.2020

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)