Standards › Standard 26 › Policies
Policy · DIA-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 26.1
At a glance
- Water for dialysis fluid and dialyser reprocessing meets the documented chemical and microbiological requirements.
- Water is tested on the schedule set in WAT-SOP-001, and each result is recorded (WAT-FRM-001).
- Every result is reviewed, and an out-of-range result stops use until acted on.
- No patient is dialysed on water that has not been tested in date.
- Stop and get help straight away if: patients are dialysed on water that was never tested.
1. Purpose
To make sure the water used for dialysis is tested to a documented standard, and acted on (26.1).
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
The water used to make dialysis fluid goes into the patient’s blood. Impure water can cause serious harm within a single session, so it must be treated and tested to a written standard.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Dialysis unit lead | Owns the water standard and the test schedule | Clinician or manager |
| Water technician or nurse | Tests and records each result | Staff |
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. Test on schedule.
- Test the water on the schedule, and record each result on WAT-FRM-001.
Key point: Tested.
Step 2. Review.
- Review each result against the requirement.
Key point: Reviewed.
Step 3. Act.
- Stop use of the water on an out-of-range result, and act before use resumes.
Key point: Acted on.
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 |
|---|---|---|---|---|
| Water tests in date and within requirement | 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 |
|---|---|---|
| WAT-FRM-001 | Water test record (existing, reused) | 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)