No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Organisationshandbuch (31.12.2022)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Organisationshandbuch (31.12.2022)
RM05	Pain management Organisationshandbuch (31.12.2022)
RM06	Fall prophylaxis Organisationshandbuch (31.12.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Organisationshandbuch; Pflegestandard zur Dekubitusprophylaxe bzw. bei bestehendem Dekubitus (31.12.2022)
RM08	Regulated handling of custodial measures Organisationshandbuch (31.12.2022)
RM09	Regulated handling of occurring malfunctions of devices Organisationshandbuch (31.12.2022)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Palliativbesprechungen Qualitätszirkel Pathologiebesprechungen Adipositas-Konferenz (Fallbesprechung hinsichtlich OP-Indikation); Pathologiebesprechungen erfolgen z.B. im Rahmen der wöchentlichen Tumorkonferenzen
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 Organisationshandbuch; Patientenidentifikation und Vermeidung von Verwechslungen/Blutkonservenverfall (31.12.2022)
RM15	Preoperative, complete presentation of necessary findings Organisationshandbuch (31.12.2022)
RM16	Procedure to avoid procedural and patient mix-ups Organisationshandbuch (31.12.2022)
RM17	Standards for recovery and postoperative care Organisationshandbuch (31.12.2022)
RM18	Discharge management Organisationshandbuch (31.12.2022)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Ende 2021 erfolgte ein Upgrade des digitalen Meldesystems für kritische Ereignisse und Beinahe-Schäden. Integriert wurde dabei eine detaillierte Info-Seite für Meldende.

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 31.12.2022
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 jährlich

No.

Explanation

IF01

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

As of: 31.12.2022

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 jährlich

Across all institutions

Conference committee

Conference frequency: bei Bedarf

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)