No.	Explanation
RM02	Regular further education and training measures
RM03	Employee surveys
RM05	Pain management Handlungsempfehlung Schmerzmanagement in der Pflege bei akuten und chronischen Schmerzen - https://md-bund.de/themen/pflegequalitaet/expertenstandards-in-der-pflege.html (01.06.2022)
RM06	Fall prophylaxis Expertenstandard Sturzprophylaxe des Deutsches Netzwerk für Qualitätsentwicklung in der Pflege - https://www.dnqp.de/fileadmin/HSOS/Homepages/DNQP/Dateien/Expertenstandards/Sturzprophylaxe_in_der_Pflege/Sturz_2Akt_Auszug.pdf (01.08.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Beschluss der FG Pflege Dekubitusprophylaxe - https://www.dnqp.de/expertenstandards-und-auditinstrumente/ (01.06.2017)
RM08	Regulated handling of custodial measures Konzernregelung und Checkliste Freiheitsentziehende Maßnahmen (12.03.2024)
RM09	Regulated handling of occurring malfunctions of devices Verfahrensstandard Umgang mit Produktproblemen (01.06.2023)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen 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 Konzernregelung OP-Sicherheit (27.01.2022)
RM15	Preoperative, complete presentation of necessary findings Konzernregelung OP-Sicherheit (27.01.2022)
RM16	Procedure to avoid procedural and patient mix-ups Konzernregelung OP-Sicherheit (27.01.2022)
RM17	Standards for recovery and postoperative care Fachgruppenbeschluss zur Erhebung des Early Warning Scores bei Verlegung aus dem Aufwachraum (10.03.2023)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: bei Bedarf

Measures

Aus den gemeldeten/ registrierten Ereignissen erfolgt jeweils eine individuelle Anpassung des betroffenen Prozesses auf der Basis von PDCA.

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 21.02.2018
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 jährlich

No.

Explanation

IF01

Documentation and procedural instructions for handling the error reporting system are available

As of: 21.02.2018

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 jährlich

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)