Title Page

  • Conducted on

  • Prepared by

  • Location
  • Date of observations

  • Dialysis Nurse:

  • Dialysis Tech:

  • Nephrologist

  • Location of treatment:


  • Patient Number (MRN or Encounter):

  • There is consent to place a vascular access device.

  • There is a consent for hemodialysis (according to organization policy).

  • Hepatitis profile performed prior to dialysis or at time of first treatment.

  • Pre-dialysis weight is documented.

  • The order for dialysis includes all of the following:

  • There is a consent for blood (if ordered).

  • Protocols are documented on the record (i.e. if a hypotension protocol is ordered PRN, a copy of it is on the record or described in the order).

  • Completed dialysis flow sheet.

  • Care plans address dialysis.

  • All entries are timed, dated and authenticated.

  • Handoff communications are documented (if required by policy).

  • There is patient education documented regarding dialysis.

  • Comments:

Blood Administration Safety

  • The blood or blood product is matched to the order.

  • The blood or blood product is matched to the patient.

  • There is a 2 person verification process (or one person if accompanied by automated identification technology such as bar coding).

  • One individual conducting the ID verification in the 2 person verification process is the qualified person administering the blood.

  • The second person in the verification process is qualified to participate in the process as determined by the hospital.

  • The blood tag is completed and returned to the blood bank at the conclusion of the transfusion.

  • Vital signs during transfusion are monitored according to hospital policy.

  • There is a policy addressing reactions to blood and blood products.

  • Comments:

Arteriovenous fistula/graft (dis)cannulation

  • Mask worn properly.

  • Hand hygiene performed (staff).

  • Don new clean gloves.

  • Apply skin antiseptic and allow it to dry. (No contact with site after antiseptic)

  • Insert needles aseptically (mask/PPE).

  • Connect blood lines aseptically.

  • Remove gloves and perform hand hygiene.

  • To discannulate:<br>Mask worn properly.

  • Perform hand hygiene and don clean gloves.

  • Disconnect from blood lines aseptically and activate needle retraction device.

  • Clean gloves worn to compress site.

  • Clean bandage applied.

  • Gloves removed and hand hygiene performed.

Catheter connection and disconnection

  • Mask / PPE appropriately donned.

  • Hand hygiene performed.

  • New clean gloves donned,

  • Catheter hub scrubbed with antiseptic.

  • Hub allowed to dry.

  • Blood tubes connected aseptically.

  • Disconnection:<br>- Hand hygiene performed and clean gloves donned<br>- aseptically disconnect blood tubings from catheter<br>- new caps placed on catheter aseptically<br>- gloves removed<br>- hand hygiene performed.

Environmental Considerations

  • Quality controls performed (water - RO/DI)

  • Machines are cultured.

  • Appropriate cleaning process between patients (machines and environment)

  • Patient privacy observed.

  • Dialysis machines listed in hospital biomedical equipment inventory (even if owned by contractor).

  • Dialysis machines risk rated as critical in inventory (failure in use is potentially life threatening)

  • Dialysis machines PM'd on schedule

  • Dialysis machine repair records shared with hospital.

  • Appropriate storage used in the assigned dialysis area.

  • Comments:

Oversight & PI

  • Dialysis contractor reports quality controls to infection preventionist.

  • Outcome metrics reported to the hospital.

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