品管路径在输血病历改进中的效果评价

Effect Assessment of Quality Control Path in Blood Transfusion Medical Improvement

目的通过对某院输血病历相关问题的分析,制定相应的整改措施。方法通过调查某院输血病历改进前及改进后内科、外科输血病历缺陷情况,调查项目包括输血记录内容、输血知情同意书、输血前的化验单等情况。结果改进后的输血病历缺陷次数构成比,内科为14%、外科为19.4%;明显少于改进前的输血病历缺陷次数构成比,内科为35.2%、外科为46.5%。改进后的病历甲级率内科为95.3%、外科为82.4%明显高于改进前的病历甲级率内科为66.8%、外科为52.6%。结论推行品质管理路径,坚持持续改进,对于提升输血病历的内涵质量及避免医疗纠纷发生具有积极的意义。

Objective Through the analysis of issues related to the hospital blood transfusion medical record, formulated rectification measures. Methods We investigated the defects in our hospital blood transfusion records before and after improvement. The survey includes blood transfusion records, blood transfusion records consent, blood transfusion, laboratory test reports before blood transfusion, etc. Results The improved blood transfusion medical record number of defect constituent ratio（internal medicine is 14%,surgery is 19.4%） is less than the before improvement（internal medicine is 35.2%, surgery is 46.5%）. The improved medical record rate of grade A（internal medicine is 95.3%, surgery is 82.4%） is better than that of before improvement（internal medicine is 66.8%,surgery is 52.6%）. Conclusions The effective investigation and analysis, aiming at the defects rectification efforts, promote the quality of management, adhere to continuous improvement, improve the quality of blood transfusion records for the connotation and avoid the occurrence of medical dispute.