No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (15.10.2022)
RM02	Regular further education and training measures
RM04	Clinical emergency management übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (15.10.2022)
RM05	Pain management übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (15.10.2022)
RM06	Fall prophylaxis übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (15.10.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (15.10.2022)
RM08	Regulated handling of custodial measures übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (15.10.2022)
RM09	Regulated handling of occurring malfunctions of devices übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (15.10.2022)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Qualitätszirkel Fallbesprechungen
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 übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (15.10.2022)
RM15	Preoperative, complete presentation of necessary findings übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (15.10.2022)
RM16	Procedure to avoid procedural and patient mix-ups übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (15.10.2022)
RM17	Standards for recovery and postoperative care übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (15.10.2022)
RM18	Discharge management übergreifende Qualitäts- und/oder Risikomanagement-Dokumentation (15.10.2022)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: quartalsweise

Measures

Es wurden vielfältige Maßnahmen zur Verbesserung der Patientensicherheit umgesetzt. Beispiele: - seit 2016: Jährlicher Patientensicherheitstag - seit 2017: DEKRA Zertifikat Patientensicherheit - Patientenidentifikationsarmbänder - OP-Sicherheitscheckliste - Audits (z.B.Arzneimitteltherapie-sicherheit,Notfall-,Pflege-,OP-,Eingriffs-und Entlassmanagement, Dokumentation) - M&M-Konferenzen - Strukturierte Fallanalysen nach London-Protokoll - Broschüre Sicherheit im Krankenhaus für Patienten

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 06.08.2023
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 quartalsweise

No.

Explanation

IF01

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

As of: 06.08.2023

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 quartalsweise

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)