WAKE DIALYSIS CLINIC

ADVERSE PATIENT OCCURRENCE FORM (APO’S)

PATIENT NAME_____________________DATE OF APO__________________TIME_______
PATIENT AGE TYPE OF DIALYSIS ________________
DID APO RESULT IN ADMISSION?__________COMMENTS (HEMO, CAPD)________
I. ACCESS-RELATED PROBLEMS:
________STENOSIS / ISCHEMIA ______HEMORRHAGE
THROMBOSIS INADEQUATE BLOOD FLOW RATE
ANEURYSM NEEDLE INSERTION DIFFICULTY
INFILTRATION OTHER:
TYPE OF ACCESS: AV FISTULA_______AV GRAFT__________ S/C
FEMORAL _________OTHER _
II. INFECTION: TYPE OF ACCESS:______________________
_________ACCESS INFECTION ___________FEBRILE REACTION OTHER:
SIGNS / SYMPTOMS: ____________________

III. BLOOD LOSS:

_________TUBING SEPARATION _________BLOOD LEAK _________HEPARINIZATION

_________CLOTTED DIALYZER / BLOOD LINES
_________POST DIALYSIS BLEEDING > 30 min. OTHER:_____________________
IV. SIGNIFICANT COMPLAINT OF CARE:
_________UNAVAILABILITY OF PHYSICIAN _____________CARE INCONSIDERATE
_________LACK OF STAFF_________________________OTHER:_____________________
V. EMERGENCY / UNPLANNED DIALYSIS: __________YES _______________NO
DESCRIBE OCCURRENCE:__________________________________________________
VI. PATIENT EXPERIENCING ONE OR MORE OF THE FOLLOWING DURING OR IMMEDIATELY
FOLLOWING TREATMENT (REQUIRING MD ATTENTION)
___________HYPOTENSION _______________HYPERTENSION
ARRHYTHMIA HYPERKALEMIA
CARDIAC RESPIRATORY ARREST AIR EMBOLISM
THROMBOTIC EMBOLISM TRANSFUSION REACTION
HEMOLYSIS CHANGE IN MENTAL STATUS
UNANTICIPATED TERMINATION BY SEIZURE, CONVULSION,
OF TREATMENT UNRESPONSIVENESS
DISEQUILIBRIUM SYNDROME DEATH
DISINFECTANT TOXICITY DEVIATION IN ULTRAFILTRATION
PULMONARY EDEMA, CHF, FLUID CHEST PAIN
OVERLOAD
___________ADMISSION DURING/ FOLLOWING OTHER:________________________
EXPLAIN:
VII. ADVERSE EFFECT BECAUSE EQUIPMENT MALFUNCTION:
__________ALARM FAILURE ___ _________________WATER SYSTEM FAILURE
DIALYSATE SYSTEM FAILURE ELECTRICAL
DEFECTIVE SUPPLIES
PHYSICIAN RECOMMENDATION:

QA COMMITTEE RECOMMENDATION:

PHYSICIAN SIGNATURE:____________________________________________DATE:
PERSON FILING REPORT SIGNATURE :_______________________________ DATE: