临床输血病案干预前后质量对比分析

Quality Contrastive Analysis on the Clinical Blood Transfusion Medical Records before and after Intervention

目的通过调查临床输血病案,更好的规范输血病案的书写,提高临床输血安全性。方法对临床输血终末病案随机检查及时干预,并进行统计分析。结果在1280份输血病案中,干预前病案640份,合格病案438份,干预后病案640份,合格病案544份。输血病案合格率从68.44%提高到85.00%。干预前后输血病案有明显差异,两者相比具有差异性(P<0.05)。结论输血病案存在不同程度缺陷,输血指证不明确,医院应持续加强医务人员的输血相关法律法规培训,加强科学合理用血宣传培训力度,规范临床病案书写。

Objective To standardize the writing of clinical medical records and improve the security of clinical blood transfusion through investigating clinical blood transfusion medical records.Methods To conduct an intervention on the blood transfusion medical records and make a random inspection on the blood transfusion terminal medical records.Results In all of the 1280 cases of blood transfusion medical records,there were 982 cases were qualified and 298 cases failed.640 cases of blood transfusion medical records were before the intervention and 438 in which were qualified,while 544 cases were qualified in the 640 cases after intervention,the qualified rate was increased from 68.44% to 85.00%.There was significant difference before and after the intervention of blood transfusion medical records,and there were statistical difference（P0.05）.Conclusion There were different degrees of defects existing in the blood transfusion medical records,and the blood transfusion evidence was inaccurate.The hospital should strengthen the training of related laws on blood transfusion among the medical staff,and also emphasize the publicity and training of reasonable blood transfusion as well as standardize the writing of medical records.