458份临床输血病历质量检查结果分析及应对策略

Analysis of 458clinical transfusion medical quality test results and coping strategies

目的：分析临床输血病历中存在的问题，探讨通过加强对输血病历的管理，促进临床输血的规范化，提高临床输血的安全性，防范输血所致医疗纠纷的发生。方法：以《临床输血技术规范》、《医疗机构临床用血管理办法》为主要依据，每周随机抽查内、外科运行病历各6～10份，对输血病历中的输血相关文书、输血医嘱、输血适应证、护理输血医嘱执行情况、输血不良反应等进行检查，并现场反馈，每个月将检查结果进行通报，提出整改意见。结果：2012-03—2013-02共随机抽查住院患者输血病历为458份，外科265份（57．86％），内科193份（42．14％）；其中，存在缺陷病历159份（32．78％），外科123份（77．36％），明显高于内科（36份，22．64％）；以患者输血知情同意书和输血病程记录存在缺陷最为常见。结论：部分临床医生对输血病历质量的重要性认识不足，应通过对输血病历的标准化和规范化，加强对临床输血病历质量的检查、分析和改进，增强医护人员对临床输血风险的认识，提高临床输血的安全、合理性，主动防范输血医疗纠纷发生。

Objective：To analyze the problems of clinical transfusion medical records,explore by strengthening blood transfusion medical records management to promote the standardization of clinical transfusion, improve clini- cal transfusion safety,and prevent medical disputes caused by blood transfusion. Method： ＂Clinical blood transfu- sion technical specifications＇and Medical institution clinical blood management approach＂were used as the main basis for the study. 6 to l0 cases were randomly selected from the medical and surgical operation records weekly, the transfusion-related instruments, blood transfusion medical advice, transfusion indications, nursing transfusion order executive and adverse transfusion reactions in the medical records were checked and live feedback. Sampling results would be reported monthly, and put forward rectification opinions. Result： 458 hospitalized patients with transfusion records were randomly selected from March 2012 to February 2013, including 265 surgical records （57.86 % ）and 193 medical records（42.14 % ）. Among them, 159 medical records had defective parts（ 32.78 % ）, 123 surgery （77.36% ） was significantly higher than internal medicine（36,22.64 %）. The defects of patient transfusion informed consent and transfusion progress notes were most common. Conclusion.. Some clinicians have insufficient understanding on the importance of the quality of transfusion medical records. It should be note that by standardi- zing and normalizing transfusion medical records to enhance the check,analysis and improvement of the quality of clinical transfusion medical records,enhance staff awareness of clinical transfusion risk,and improve clinical trans- fusion safety and rationality,so as to proactive prevent transfusion medical disputes.