No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Risikomanagement-Handbuch Niels-Stensen-Kliniken, Dokumenten-Nr.: 016369 (12.10.2021)
RM04	Clinical emergency management Verfahrensanweisung Notfallmanagement MHA, Dokumenten-Nr.: 000817 (13.07.2020)
RM05	Pain management Leitlinie Akutschmerztherapie NSK, Dokumenten-Nr.: 004684 (28.04.2020)
RM06	Fall prophylaxis Standard Sturzprophylaxe MHA, Dokumenten-Nr.: 010317 (13.07.2020)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Standard Dekubitusprophylaxe MHA, Dokumenten-Nr.: 000855 (13.07.2020)
RM08	Regulated handling of custodial measures Freiheitsentziehende Maßnahmen NSK, Dokumenten-Nr.: 014967 (12.04.2019)
RM09	Regulated handling of occurring malfunctions of devices Verfahrensanweisung Meldung von Vorkommnissen mit Medizinprodukten NSK, Dokumenten-Nr.: 013311 (24.07.2018)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Mortalitäts- und Morbiditätskonferenzen
RM12	Use of standardised information sheets
RM13	Application of standardised surgical check lists
RM16	Procedure to avoid procedural and patient mix-ups OP-Sicherheits-Checkliste MHA, Dokumenten-Nr.: 013835 (20.12.2017)
RM17	Standards for recovery and postoperative care Verfahrensanweisungen Aufwachraum MHA, Dokumenten-Nr.: 008182 (13.07.2020)
RM18	Discharge management Verfahrensanweisung Entlassungsmanagement MHA, Dokumenten-Nr.: 013695 (13.07.2020)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: wöchentlich

Measures

Beispiel-Meldungen: Nr. 1721: Mini-Redon (kein Sog) / Nr. 1748 MANV (fehlerhafte externe Kapazitätsabfrage) / Nr. 1868: Assistenzärzte (Qualifizierung) / Nr. 1773: Notruf (technischer Defekt)

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 26.03.2021
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 bei Bedarf

No.

Explanation

IF01

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

As of: 26.03.2021

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 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)