According to the statistics of this project, the average number of cases with abnormal body weight in the first quarter of 2020 was one. However, this number increased to four in the first quarter of 2021. Moreover, two of these cases resulted in pulmonary edema and shock, leading to complaints from their families. The nurses, who were scolded and discouraged by angry family members, lost confidence, which served as a motivation for improvement. The main problems identified during the analysis are as follows: nurses’ lack of recognition of correct weight measurement during hemodialysis, nurses’ failure to implement two-person review of dialysis machine settings, patients’ and primary caregivers’ lack of awareness regarding correct weight measurement during hemodialysis, and insufficient availability of in-service education and health education tools for proper weight measurement. To address these issues, the following measures were implemented: arrangements for education and training, formulation of standards, production of diverse and multi-language health education tools, and utilization of the LINE@kidney care service platform. As a result, the number of weight abnormalities during hemodialysis treatment decreased from four to zero, and no abnormalities were observed until the fourth quarter of 2021. The implementation of these improvements significantly reduced the workload of nurses and enhanced the quality and safety of dialysis care for patients.
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