No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available QMH (01.04.2023)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Diverse Notfalldokumente (Checklisten, Formulare) (01.04.2023)
RM05	Pain management Leitfaden:Empfehlung zur SchmerztherapieAutor: PD Dr. M. Freitag; Dr. J-H Stork (01.04.2023)
RM06	Fall prophylaxis Pflegestandard Sturzprophylaxe (basierend auf dem Expertenstandard Sturzprophylaxe) (29.04.2023)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Pflegestandard Dekubitusprophylaxe (basierend auf dem Expertenstandard Dekubitusprophylaxe) (01.06.2023)
RM08	Regulated handling of custodial measures Verfahrensanweisung Umgang mit freiheitsentziehenden Maßnahmen (01.04.2023)
RM09	Regulated handling of occurring malfunctions of devices Reparaturformular Medizintechnik (01.04.2023)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Pathologiebesprechungen Palliativbesprechungen
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 QMH (01.04.2023)
RM15	Preoperative, complete presentation of necessary findings QMH (01.04.2023)
RM16	Procedure to avoid procedural and patient mix-ups VA Maßnahmen zur Vermeidung von Patientenverwechselungen, VA Patientenidentifikation Endoskopie, Workflow Sichere Patientenidentifikation in der Aufnahme, VA Patientenidentität OP/Anästhesie (27.01.2023)
RM17	Standards for recovery and postoperative care SOP postoperative Überwachung auf den Normalstationen (25.04.2023)
RM18	Discharge management Verfahrensanweisung Sozial und EntlassmanagementSOP Entlassungsmanagement in der Pflege (12.01.2023)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: quartalsweise

Measures

CIRS; Fehlermeldeformulare; Risikochecklisten sowie definierter Prozess zur Patientensicherheit. Arzneimittelüberwachungssoftware. Arzneimittelvisiten durch Apothekerin. Erfassungs- und Auswertungssoftware nosoommialer Infektionen. Qualitätszirkel und M&M-Konferenzen der Fachabteilungen und des viszeralonkologischen Zentrums. Zertifiziertes Beschwerdemanagement

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 01.10.2023
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 monatlich

No.

Explanation

IF01

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

As of: 01.10.2023

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 monatlich

Across all institutions

Conference committee

Conference frequency: monatlich

No.	Explanation
	Other
	Other
EF01	CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association)

No.

Explanation

Other

EF01

CIRS AINS (Professional Association of German Anaesthetists and German Society for Anaesthesiology and Intensive Care Medicine, German Medical Association)