临床输血病历质量调查与持续改进措施的初步探讨

Preliminary discussion of clinical blood transfusion medical record quality investigation and continuous improvement measures

目的：规范临床用血病历书写，提高输血疗效，确保临床用血质量，为处理输血治疗而导致的医疗纠纷提供法律依据。方法：以卫生部《医疗机构临床用血管理办法》（85号令）、《临床输血技术规范》[2000]、《广东省医院输血技术规范》为依据，按照《三甲综合医院评审标准实施细则（2011年版本）》（输血管理与持续改进）要求，抽查我院2012年1月～2014年12月住院归档输血病历，每季度约100份，进行调查分析总结。结果：2014年较2012年份输血病历存在相关不合格项的问题均有不同程度的改进，改进中和改进后的相关数据有统计学意义（χ^2改进中=197.19,P改进中＜0.01,χ^2改进后=129.71P改进后＜0.01）。结论：通过加强监督管理临床输血病历的规范书写，加强临床合理用血的培训，建立有效的输血医疗质量管理模式，促进临床用血管理和持续改进，保障临床安全、有效和科学用血。

Objective：To improve the efficacy of blood transfusion and ensure the quality of blood for clinical use by standardizing the medical record writing of blood for clinical use, and provide legal backing to resolve medical disputes caused by blood transfusion therapy.Methods： Basis on the management measures of blood for clinical use in medical institution（No.85 order）, the technical specifications of clinical blood transfusion （2011） and the technical specifications of blood transfusion in Guangdong Province. According to the requirement of the implementation rules of three-A comprehensive hospital appraisal standard（2011） （blood transfusion and continual improvement）, 1440 medical records of blood transfusion from January 2012 to December 2014 （100 medical records of each quarter） were analyzed.Results：The nonconforming items of medical records of blood transfusion in 2013 ＆2014 had made different improvement, the various data of improvement and improved were better than those in former, the difference was statistically significant （P〈0.01）.Conclusions：By strengthening the supervision and management of medical record writing of clinical transfusion, strengthening the training of blood for clinical use, establish a effective mode of medical quality for blood transfusion, promote the management and continual improvement of blood for clinical use, and ensure the safety, efficacy and science of blood for clinical use.