输血病历质量分析与医疗安全

Quality analysis of blood transfusion record and transfusion safety

目的 :加强医院病历质量规范管理,分析输血病历存在的问题,改进和完善输血病历的质量,以提高临床输血的安全性。方法:根据《病历书写基本规范》、《临床输血技术规范》等相关制度要求,制定输血病历质量检查标准,对3年中所有归档的1 856份输血病历进行质量分析,从中总结输血病历中存在的不足,并提出防范的相关对策。结果:输血病历质量符合检查标准的占83.1%(1 543/1 856),不符合检查标准占16.9%(313/1 856),不达标的输血病历在逐年下降;非手术科室输血病历达标率明显高于手术科室,两者比较有统计学差异(P<0.001);而313份不合格输血病历中输血治疗病程记录不合格最为明显,占64.5%(202/313),其次"输血治疗同意书"不合格率为29.4%(92/313)。结论:建议定期开展输血病历质量督查,有效提高输血病历质量,规范输血管理,确保医疗安全,避免医疗纠纷。

Objective： To analyze the blood transfusion problems, improve writing quality of blood transfusion record, strengthen the quality of hospital record management, and improve the safety of blood transfusion. Methods： In accordance with the ＂fundamental requirements of medical record＂ and ＂technical specifications of blood transfusion＂,standardized quality inspection of blood transfusion record was formulated and quality analysis of 1 856 blood transfusion records within 3 years was performed, and preventive measures were suggested. Results： Blood transfusion record met the inspection standard accounted for 83.1%（1 543 / 1 856）, and 16.9%（313 / 1 856） did not meet the inspection standard.The inspection standard meeting rate in non-surgery departments was significantly higher than that of surgery departments（P 〈0.001）. Of the 313 not qualified transfusion records, records not fulfilled the requirements of transfusion record accounted for 64.5%（202/313）, and unqualified consent form accounted for 29.4%（92/313）. Conclusions： Regular quality inspection and quality supervision of blood transfusion record could improve effectively the quality of blood transfusion record, enhancing blood transfusion management, ensuring transfusion safety and avoiding medical dispute.