No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QM Konzept / Sicherheitsmanagement (05.10.2023)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Medizinisches Notfallmanagement / Alarm- und Katastrophenplan (MANV) (27.06.2023)
RM05	Pain management Konzept Schmerztherapie (27.05.2023)
RM06	Fall prophylaxis Sturzprophylaxe (13.09.2023)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Dekubitusprophylaxe (16.02.2023)
RM08	Regulated handling of custodial measures Fixierung (05.10.2023)
RM09	Regulated handling of occurring malfunctions of devices QM Konzept / Sicherheitsmanagement (05.10.2023)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen 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 Perioperative Patientencheckliste gemäß WHO (14.06.2023)
RM15	Preoperative, complete presentation of necessary findings Perioperative Patientencheckliste gemäß WHO (14.06.2023)
RM16	Procedure to avoid procedural and patient mix-ups Perioperative Patientenchecklsite gemäß WHO (14.06.2023)
RM17	Standards for recovery and postoperative care SOP zur Intensivmedizin (17.05.2023)
RM18	Discharge management Entlassmanagement (08.10.2023)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Perioperative Checkliste, M&M Konferenzen, Risikoaudits, Aktionsbüdnis Patientensicherheit

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 13.04.2023
IF02	Internal evaluation of the received reports taken quartalsweise
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: 13.04.2023

IF02

Internal evaluation of the received reports

taken quartalsweise

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: quartalsweise

No.	Explanation
	Other
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)

No.

Explanation

Other

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)