病案中输血记录质量的调查与分析

Investigation of Blood Transfusion Medical Records

目的探讨输血病案书写规范，提高输血病案质量。方法分别随机抽取于2010年和2011年在成都市第三人民医院行输血治疗的住院患者输血病案各200份作为研究对象（本研究遵循的程序符合成都市第三人民医院人体试验委员会所制定的伦理学标准，得到该伦理会批准）。由专人对400份病案逐份检查：“备血医嘱、输血记录、护理记录、知情同意书、输血前相关项目检查及配发血记录”等6个项目，记录各项的缺陷次数，计算不合格率。对2010年和2011年所抽查输血病案各项不合格率进行统计学处理。结果2010年与2011年输血记录质量的同查结果显示，“知情同意书”和“输血前相关项目检查”2项的不合格率比较，差异有统计学意义（P〈0．05）。结论本院2011年输血病案较2010年质量有所提高，填写更加规范。通过规范输血病案书写和提高输血病案质量，有助于加强输血的安全管理，减少和避免输血导致的医疗纠纷发生。

Objective To investigate the written specifications of blood transfusion medical records, and improve the quality of transfusion medical records. Methods Two hundreds copies of blood transfusion medical records were randomly collected from patients who received blood transfusion in the Third People＇s Hospital of Chengdu in 2010 and 2011, respectively （The study protocol was approved by the Ethical Review Board of Investigation in Human Being of the Third People＇s Hospital of Chengdu）. All these 400 records were inspected by professionals. The failure rates of each item were calculated, and compared by chi-square test. Results Compared the differences of failure rate in 2010 to 2011, there was statistically significant in the items of informed consent and before transfusion-related examination （P 〈 0.05 ）. Conclusions The quality and standardization of transfusion medical records of the Third People＇s Hospital of Chengdu have increased in 2011. Through regulating blood transfusion medical record writing, the safety management of blood transfusion has strengthen, and the medical malpractice about blood transfusion has reduced.