No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitäts- und Risikopolitik (13.06.2022)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Zentrale Nofallorganisation mit umfänglichen SOPs und Verfahrensanweisungen (01.06.2021)
RM05	Pain management Konzept Schmerzmanagement und interdisziplinäres postoperatives Schmerzmanagement (07.11.2022)
RM06	Fall prophylaxis Zum Thema Sturz liegen umfängliche schriftliche Regelungen wie z.B. VA "Sturzrisikofaktoren", Checkliste "Sturzrisikofaktoren" und Checkliste "Sturzpräventionsmaßnahmen" vor. (05.12.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubituspräventionskonzept (05.12.2022)
RM08	Regulated handling of custodial measures Umgang mit freiheitsentziehenden Maßnahmen ist durch umfängliche zentralen Verfahrensanweisung, Empfehlungen und Formularen geregelt. (15.06.2020)
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
RM14	Preoperative summary of predictable critical surgical steps, surgical time and expected blood loss Standardisierte OP-Checkliste (04.07.2022)
RM15	Preoperative, complete presentation of necessary findings Strukturierter Ablauf Einschleusen von Patienten (20.06.2022)
RM16	Procedure to avoid procedural and patient mix-ups Standard zur Kennzeichnung des OP-Gebietes (18.07.2022)
RM17	Standards for recovery and postoperative care Standards Ausschleusen, Strukturierte Patientenübergabe postoperativ, Ärztlicher Dienst im Aufwachraum (06.09.2021)
RM18	Discharge management Verfahrensanweisungen nach Vorgaben des Rahmenvertrages Entlassmanagement (26.05.2021)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: bei Bedarf

Measures

Bsp.: VA "Sichere Patientenidentifikation", edv-gestützte Spritzenbeschriftung; edv-gestützten Fluidmanagement auf der Intensivstation; OP-Checkliste, VA "Ein- und Ausschleusen im OP"; digitale Patientenakte Intensivstation; digitales Patientenmanagement ZNA; Patientenbroschüre "Sicher im Krankenhaus", VA "Umgang mit Patienteneigentum", Etablierung "Interdisziplnäres Team Patientensicherheit", Teilnahme "Tag der Patientensicherheit"

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 15.03.2022
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: 15.03.2022

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)
EF02	CIRS Berlin (Medical Association Berlin, 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)
EF06	CIRS NRW (North Rhine and Westphalia-Lippe Medical Chambers, North Rhine Westphalia Hospital Association, North Rhine and Westphalia-Lippe Association of Statutory Health Insurance Doctors, German Medical Association, National Association of Statutory Hea
EF12	“Every mistake counts” (Institute for General Medicine Frankfurt)