Standards › Standard 26 › Standard operating procedures (SOPs)
Procedure · DIA-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 26.3
At a glance
- Prepare each concentrate and mix each batch of dialysis fluid to the written procedure.
- Identify each batch with its date, its preparer and its concentration (DIA-FRM-002).
- Check the concentration before the batch is used.
- Do not mix a batch from memory.
- Stop and get help straight away if: a batch of fluid is mixed from memory, with the wrong concentration.
1. Purpose
To make sure every batch of dialysis fluid is prepared to the written procedure and traced (26.3).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Dialysis fluid made with the wrong concentration or in the wrong order can cause a serious event in the patient. Following a written procedure for every batch prevents the error.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Dialysis nurse preparing fluid | Prepares and records each batch | Clinician |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Follow the procedure.
- Prepare and mix the batch exactly to the written procedure.
Key point: Prepared.
Step 2. Check and label.
- Check the concentration and label the batch with its identity.
Key point: Labelled.
Step 3. Record.
- Record the batch on DIA-FRM-002.
Key point: Recorded.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Batches prepared to the procedure and recorded | 100% | Monthly | Dialysis unit lead | Escalate to medical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| DIA-FRM-002 | Batch preparation record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on ISO 23500:2019 (fluids for haemodialysis) and the KDIGO Clinical Practice Guideline for Hemodialysis Adequacy (2015 update). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
- Dialysis & Renal Replacement Therapy (AMB-12)
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)