No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikomanagement VARisikomanagement HandbuchDarstellung des QM-Systemsweitere Verfahrensanweisungen (30.09.2023)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Notfallmanagement VA (Dr. M. Reitz), Notfälle Aushang IN, Feedback Notfallmanagement, mehrere CL, Basic Life Support VA, ACLS Algorithmus Herzstillstand VA. (02.08.2023)
RM05	Pain management Risikomanagement VARisikomanagement HandbuchDarstellung des QM-Systemsweitere Verfahrensanweisungen (30.09.2023)
RM06	Fall prophylaxis Risikomanagement VARisikomanagement HandbuchDarstellung des QM-Systemsweitere Verfahrensanweisungen (30.09.2023)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Risikomanagement VARisikomanagement HandbuchDarstellung des QM-Systemsweitere Verfahrensanweisungen (30.09.2023)
RM08	Regulated handling of custodial measures Risikomanagement VARisikomanagement HandbuchDarstellung des QM-Systemsweitere Verfahrensanweisungen (30.09.2023)
RM09	Regulated handling of occurring malfunctions of devices MPG Störungsmeldung-Reparaturanforderung VA \| Herr Wissemann (07.09.2023)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen
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 Risikomanagement VARisikomanagement HandbuchDarstellung des QM-Systemsweitere Verfahrensanweisungen (30.09.2023)
RM15	Preoperative, complete presentation of necessary findings Risikomanagement VARisikomanagement HandbuchDarstellung des QM-Systemsweitere Verfahrensanweisungen (30.09.2023)
RM16	Procedure to avoid procedural and patient mix-ups Risikomanagement VARisikomanagement HandbuchDarstellung des QM-Systemsweitere Verfahrensanweisungen (30.09.2023)
RM17	Standards for recovery and postoperative care Risikomanagement VARisikomanagement HandbuchDarstellung des QM-Systemsweitere Verfahrensanweisungen (30.09.2023)
RM18	Discharge management Entlassmanagement VA (01.07.2023)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Im Rahmen der internen Qualitätssicherung gibt es ein entsprechendes Meldesystem, dieses lässt auch anonyme Meldungen zu. Es gibt entsprechende Verfahrensanweisungen mit dem Hinweis auf das bundesweite CIRS. Aus diesem bundesweiten Portal werden relevante Meldungen (u.a. Fall des Monats) ausgewertet und in den Leitungsbesprechungen thematisiert.

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 23.01.2020
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: 23.01.2020

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
EF03	KH-CIRS (German Hospital Federation, Action Alliance for Patient Safety, German Nursing Council, German Medical Association, National Association of Statutory Health Insurance Doctors)