HD-CL-006-F2 · Pre-Treatment Safety Checklist (UPDATED)

Pre-Treatment Safety Checklist

Form HD-CL-006-F2 · Hemodialysis Unit – [Hospital Name]
Date: _________ Shift: ☐ AM ☐ PM ☐ Night Machine #: _
📋 Updated June 26, 2026 KDIGO 2025 aligned · UFR calculation · expanded lab alerts · CVC hub scrub mandatory
PROPOSED UPDATES
⛔ STOP Do NOT initiate dialysis if ANY shaded box is checked "NO" or if any "STOP" criteria met. Notify In-Charge RN + MD immediately.
# Safety Check / Criteria Detail / Values Yes No N/A STOP if RN Initials
A. PRESCRIPTION & ORDERS
1 Current HD Prescription HD-CL-006-F1 signed by MD within 30 days NO = STOP
2 All Parameters Ordered Qb, Qd, time, dialyzer, Na, K, Ca, Mg, temp, dry weight, heparin present NO = STOP
3 Patient ID 2 identifiers: Name + MRN/DOB. Matches prescription + armband NO = STOP
4 Allergies Reviewed. No allergy to dialyzer, heparin, meds ordered today Allergy = STOP
B. PATIENT ASSESSMENT
5 Pre-Weight _____ kg. Scale zeroed. Same clothes
6 Vital Signs Temp: ___ BP: ___ / ___ HR: ___ RR: _____
7 BP Hold Parameters BP within MD ordered limits on HD-CL-006-F1 NO = STOP + Call MD
8 Access Assessment Look, Listen, Feel done. Thrill/Bruit present. No infection/swelling Absent thrill or infection = STOP
9 CVC Exit Score If CVC: Score 0-3 documented. Score: _____ Score ≥2 = STOP
10 Signs of Fluid Overload Lungs clear, no JVD, no edema >2+ Severe overload = Call MD
C. UFR SAFETY CALCULATION UPDATED
11 Dry Weight Ordered Dry Weight: _____ kg from HD-CL-006-F1
12 UF Goal Pre-Wt ___ kg - Dry Wt ___ kg + 0.5L = _____ L
13 Treatment Time Ordered Time: _____ hrs
14 UFR Calculation UFR = UF Goal __ L × 1000 ÷ Time ___ hrs ÷ EDW ___ kg = ___ mL/kg/hr >13 = STOP
15 MD Notified if UFR >13 If >13, MD called. New orders received: _________________ >13 + No MD order = STOP
15a Lab Alerts NEW K >6.0, Hb <7 or >12, Ca >10.2, Phos >7.0, PTH >800 – call MD if present Critical lab = Call MD
D. MACHINE & WATER SAFETY
16 Machine Tests Passed Self-test complete. Air detector, blood leak, alarms tested NO = STOP
17 Dialysate Verification Conductivity: __ Temp: __ pH: _____ Within limits NO = STOP
18 Dialyzer Verified Type matches order. Not expired. Not reused if single-use NO = STOP
19 Dialysate Concentrate Na, K, Ca, Mg, Bicarb match prescription HD-CL-006-F1 NO = STOP
20 Water System Status No water alarms last 24h. Daily Cl2 log reviewed. <0.1 mg/L Cl2 >0.5 = STOP
E. MEDICATION SAFETY
21 Heparin Dose Loading __ u + Hourly __ u/hr per order. 2-RN check if high-alert Wrong dose = STOP
22 ESA/Iron Hold Check Hb __ BP __ Temp _____ Hold if: Hb >11.5, BP >180/100, febrile Hold criteria met = STOP
23 CVC Hub Scrub If CVC: Hub scrubbed with alcohol 15 sec + dry 15 sec before ANY access NO = STOP
F. FINAL VERIFICATION
24 Patient Confirms Patient states name + agrees to treatment. No new complaints Refusal = STOP
25 All "STOP" Criteria Resolved If any STOP was checked, issue resolved + MD order received Unresolved = STOP
Treatment Decision
RN Signature: Date/Time:
In-Charge RN Review if STOP: Date/Time:
MD Notified: Name: Time:
New Orders:
Form HD-CL-006-F2 · Updated June 26, 2026 KDIGO 2025 · KDOQI 2015 · MOH-Jordan 2023 aligned
This checklist must be completed before EVERY hemodialysis treatment. Any STOP criteria must be resolved before initiation.

HD-CL-006-F2 · Version 2026-06-27 · Hemodialysis Unit

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Aligned with KDOQI, AAMI/ISO, CDC, MOH-Jordan 2023, JCI 8th Ed.

✍️ Author: Ahmed Mohmad Rashyd Musleh Registered Staff Nurse