输血病案质量与医疗安全

Relationship between Quality of blood transfusion records and Medical Safety

目的为医院的病案质量管理和医疗安全提供参考。方法制定输血病案专项检查标准,对320份输血病案进行质量分析。结果病案合格率:病案首页90.93%、输血同意书91.87%、输血前化验结果83.75%、输血指征92.18%、成份输血比例91.25%、输血观察记录77.50%。结论输血病案质量直接影响病案内涵和医疗质量与安全,医院应当加强输血病案质量管理,确保医疗安全,避免医疗纠纷。

Objective To provide reference for quality management of medicalrecords and medical safety in hospital.Methods Quality analysis was conducted on 320 blood transfusion records by special examination standard.Results The qualification rate of the front sheet,blood transfusion informed consent,test results before blood transfusion,blood transfusion indication,proportion of component blood transfusion,observation records of blood transfusion were 90.93%,91.87%,83.75%,92.18%,91.25%,77.50%,respectively.Conclusion The quality of blood transfusion records directly influenced the medical records connotation and medical quality and safety,which requested the hospital to strengthen the quality management of blood transfusion records in order to ensure medical safety and avoid medical disputes.