No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitätsmanagementdokumentation im Rahmen der Dokumentenlenkungssoftware (QM-Handbuch 05.05.20, Prozessbeschreibung risikobasierter Ansatz) (21.06.2022)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Dokumente zur klinische Notfallversorgung, Klinikalarm- und Einsatzplan (KAEP) (30.12.2022)
RM05	Pain management Standards fachabteilungsspezifisch, z.B. Postoperatives Schmerzkonzept Unfallchirurgie und Orthopädie (11.07.2019)
RM06	Fall prophylaxis Standard Sturzprävention (01.06.2021)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Standard Dekubitusprophylaxe (07.06.2022)
RM08	Regulated handling of custodial measures Standard Freiheitsentziehende Maßnahmen (24.02.2022)
RM09	Regulated handling of occurring malfunctions of devices Dienstanweisung Medizinprodukte (30.07.2020)
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 OP-Checkliste (03.02.2021)
RM15	Preoperative, complete presentation of necessary findings OP-Checkliste (03.02.2021)
RM16	Procedure to avoid procedural and patient mix-ups Patientenidentifikationsarmband bei Aufnahme ; OP-Checkliste (20.06.2020)
RM17	Standards for recovery and postoperative care Standard Aufwachraum 19.04.2022 Handlungsrichtlinie Postoperative Pflege in der Kinderklinik 21.06.2019 (02.06.2021)
RM18	Discharge management Entlassmanagement,10.11.2022 Prozessbeschreibung Kinder und Jugendmedizin (06.03.2022)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: andere Frequenz

Measures

CIRS wird als klinikinternes und einrichtungsübergreifendes Fehlermeldesystem zur Ableitung von Maßnahmen bei aufgetretenen gemeldeten (beinahe) Fehlern genutzt.

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 19.05.2022
IF02	Internal evaluation of the received reports taken jährlich
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: 19.05.2022

IF02

Internal evaluation of the received reports

taken jährlich

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
EF01	CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association, National Association of Statutory Health Insurance Doctors)

No.

Explanation

Other

EF01

CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association, National Association of Statutory Health Insurance Doctors)