No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available VA_CIRS Critical Incidents Reporting/VA_Risikomanagement/VA_Fehler-Korrektur-und_Vorbeugemaßnahmen (17.11.2021)
RM02	Regular further education and training measures
RM04	Clinical emergency management VA_Notfall_OP/VA_KY_EPZ_QMH2_VA_Notfallmanagement (27.02.2023)
RM05	Pain management VA_Schmerzmanagement (20.02.2023)
RM06	Fall prophylaxis VA_Sturzprophylaxe (14.11.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Expertenstandard Dekubitus (28.02.2022)
RM08	Regulated handling of custodial measures Pflegestandards (10.12.2019)
RM09	Regulated handling of occurring malfunctions of devices VA_Ausfall_Medizintechnik (01.09.2023)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Palliativbesprechungen Qualitätszirkel Qualitätszirkel EPZ Max und Regionales Traumazentrum
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 Sicherheitscheckliste_OP (08.11.2021)
RM15	Preoperative, complete presentation of necessary findings KY_EPZ_QMH2_VA_InstitutionelleBesprechungenEPZmax (20.10.2023)
RM16	Procedure to avoid procedural and patient mix-ups KY_EPZ_QMH2_LL_Patientenidentifikation (03.11.2021)
RM17	Standards for recovery and postoperative care OP-Statut (24.11.2022)
RM18	Discharge management VA_Entlassmanagement (30.09.2022)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: quartalsweise

Measures

Einführung Qualitätsmanagement Prozessanpassung Einführung Fehlermeldesysteme

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 19.08.2019
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 bei Bedarf

No.

Explanation

IF01

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

As of: 19.08.2019

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 bei Bedarf

Across all institutions

Conference committee

Conference frequency: quartalsweise

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)