No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitätsmanagementhandbuch Klinikum Altmühlfranken (29.12.2023)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Qualitätsmanagementhandbuch Klinikum Altmühlfranken (29.12.2023)
RM05	Pain management Qualitätsmanagementhandbuch Klinikum Altmühlfranken (29.12.2023)
RM06	Fall prophylaxis Qualitätsmanagementhandbuch Klinikum Altmühlfranken (29.12.2023)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Qualitätsmanagementhandbuch Klinikum Altmühlfranken (29.12.2023)
RM08	Regulated handling of custodial measures Qualitätsmanagementhandbuch Klinikum Altmühlfranken (29.12.2023)
RM09	Regulated handling of occurring malfunctions of devices Qualitätsmanagementhandbuch Klinikum Altmühlfranken (29.12.2023)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Mortalitäts- und Morbiditätskonferenzen Palliativbesprechungen Fallbesprechungen Peer Review IQM klinische Visite (STENO) Komplikationsbesprechungen (EPZ)
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 Qualitätsmanagementhandbuch Klinikum Altmühlfranken (29.12.2023)
RM15	Preoperative, complete presentation of necessary findings Qualitätsmanagementhandbuch Klinikum Altmühlfranken (29.12.2023)
RM16	Procedure to avoid procedural and patient mix-ups Qualitätsmanagementhandbuch Klinikum Altmühlfranken (29.12.2023)
RM17	Standards for recovery and postoperative care Qualitätsmanagementhandbuch Klinikum Altmühlfranken (29.12.2023)
RM18	Discharge management Qualitätsmanagementhandbuch Klinikum Altmühlfranken (29.12.2023)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

OP-Patientensicherheitscheckliste, Endo/HKL-Patientensicherheitscheckliste, Medizinische Standards, Pflegerische Standards, Patientensicherheitsarmband, Hygienemanagement im Umgang mit multiresistenten Erregern, Aktualisierung der Regelungen "Umgang mit Medikamenten", Führen einer Risikomatrix, Veröffentlichung CIRS Fall der BKG des Monats

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 13.12.2022
IF02	Internal evaluation of the received reports taken halbjährlich
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: 13.12.2022

IF02

Internal evaluation of the received reports

taken halbjährlich

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: bei Bedarf

No.	Explanation
EF03	KH-CIRS (German Hospital Association, German Nursing Council, German Medical Association)