1. Improving patient safety - checklist for haemodialysis Tanja Lönnberg Tampere University hospital Finland

2. Pirkanmaa Hospital District – Esittäjän nimi 2 Content 1. Backround 2. Checklist 3. Tools for implementation

3. Pirkanmaa Hospital District – Esittäjän nimi 3 Why? - Construction of a new nephrological exepertiese center - Need for change: unifying scattered treating cultures and –processes - Need for cultural change in patient safety- thinking, national legistation - Need to increase quality-issues Better care for kidney patients

4. Pirkanmaa Hospital District – Esittäjän nimi 4 How? - Collecting electrical adverse event data concirning haemodialysis since 2007 (over 300 reports) - Staff inquiry in 2009 and 2012 - patient feedback - multiprofessional team analyzing risks

5. Pirkanmaa Hospital District – Esittäjän nimi 5 Analysis - 27 different risks found in haemodialysis treating process - events from near misses to severe events (no deaths) - Examples (to be listed later) Need for a patient safety tool

6. Pirkanmaa Hospital District – Esittäjän nimi 6 Checklist for haemodialysis 1. pre 2. inter 3. post

7. Pirkanmaa Hospital District – Esittäjän nimi 7 Pre haemodialysis 1. Identification 2. Treatment data Riskfactors Doctors orders Treatmentform Dry weigh parameters

8. Pirkanmaa Hospital District – Esittäjän nimi 8 Pre dialysis 3. Assesment of current medical situation Infections Need for isolation Risk for bleeding Antikoagulation assesment 4. Haemodialysis machine Equipment Parameters indicators

9. Pirkanmaa Hospital District – Esittäjän nimi 9 Pre dialysis 4. Dialysis access Working Infections Catheter intact and in place

10. Pirkanmaa Hospital District – Esittäjän nimi 10 Intra dialysis 1. Double-checking in 30 minutes 2.Observation Dialysis access Breathing Hemodynamics Blood sugar Fluid removal infections

11. Pirkanmaa Hospital District – Esittäjän nimi 11 Intra dialysis 3. Dialysis machine Indicators Cautions 4. Medication given checked

12. Pirkanmaa Hospital District – Esittäjän nimi 12 Post dialysis 1. assesment of the treatment Weight Hemodynamics Breathing Vascular access Medication Blood sugar 2. Assesment of medical condition Problems

13. Pirkanmaa Hospital District – Esittäjän nimi 13 Post dialysis 3. vascular access secured 4. dialysis machine maintained 5. reporting

14. Pirkanmaa Hospital District – Esittäjän nimi 14 Tools for implementation - long term developement - cultural change - commitment - control - feedback - management and decision making - patients involvement Continious work