No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Anwendung der QM-Software Intrafox Organisationshandbuch (15.12.2021)
RM02	Regular further education and training measures
RM04	Clinical emergency management diverse Dokumente zum Thema Notfallmanagement (15.12.2021)
RM05	Pain management RB-HB-0056 Schmerzhandbuch weitere Schmerzstandards (19.10.2023)
RM06	Fall prophylaxis RB-AA-0655 Prävention von Stürzen, Umgang mit Sturzereignissen RB-AA-1325 Expertenstandard Sturzprophylaxe (13.10.2023)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) RB-VA-1427 Expertenstandrad Dekubitus (21.05.2021)
RM08	Regulated handling of custodial measures RB-VA-0250 Fixierung von Patienten im Akutkrankenhaus weitere mitgeltende Dokumente (27.07.2022)
RM09	Regulated handling of occurring malfunctions of devices Organisationshandbuch (15.12.2021)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Pathologiebesprechungen 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 Organisationshandbuch (15.12.2021)
RM15	Preoperative, complete presentation of necessary findings Organisationshandbuch (15.12.2021)
RM16	Procedure to avoid procedural and patient mix-ups RB-FO-0034 Patienten-Sicherheits-Checkliste (OP) (27.07.2022)
RM17	Standards for recovery and postoperative care RB-AA-0698 Postoperative Überwachung im AWR (14.09.2020)
RM18	Discharge management RB-VA-0226 Entlassmanagement weitere mitgeltende Dokumente (15.12.2021)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: quartalsweise

Measures

Das Fehlermanagement ist nach den Anforderungen der DIN EN ISO 9001:2015 aufgebaut.

No.	Explanation
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

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: quartalsweise

No.	Explanation
	Other
EF06	CIRS NRW (North Rhine and Westphalia-Lippe Medical Associations, North Rhine-Westphalia Hospital Association, North Rhine and Westphalia-Lippe Associations of Statutory Health Insurance Physicians, German Medical Association)

No.

Explanation

Other

EF06

CIRS NRW (North Rhine and Westphalia-Lippe Medical Associations, North Rhine-Westphalia Hospital Association, North Rhine and Westphalia-Lippe Associations of Statutory Health Insurance Physicians, German Medical Association)