1440份临床输血病历质量分析

Quality analysis of 1440 cases of blood transfusion records

目的分析临床输血病历中存在的问题,为提高输血病历质量提供依据。方法随机抽取我院2013-2014年住院患者输血病历1 440份进行年末质量调查分析,内容包括输血申请、知情同意签署、输血前检查、输血病程记录、输血检测记录、输血后疗效评估、输血不良反应反馈等7条环节。结果 12014年输血病历中输血申请、知情同意签署、输血前检查、输血病程记录、输血监测记录、输血后疗效评估、输血不良反应反馈的不合格率相较于2013年均有所降低,但差异均无统计学意义(P>0.05)。而2014年输血病历总不合格率为12.22%,明显低于2013年的22.36%,差异有统计学意义(P<0.05);2非手术科的输血病历不合格率占比11.93%(65/545),明显低于手术科的20.56%(184/895),差异有统计学意义(P<0.05);32014年输血病历中出现过敏反应、发热反应、心力衰竭、细菌污染等的不良反应发生率相较于2013年均有所降低,但差异均无统计学意义(P>0.05)。而2014年输血病历总不良反应发生率为3.19%,明显低于2013年的6.25%,差异有统计学意义(P<0.05)。结论对临床输血病历存在的问题应及时做好反馈与整顿工作,实施有效的输血管理制度,加强医务人员对安全输血相关的法律法规的认识,对提高输血病历质量、降低不良反应发生率有着积极的促进作用。

Objective To analyze the existing problems of clinical blood transfusion records, and provide ba-sis for improving the quality of blood transfusion records. Methods A total of 1 440 blood transfusion records of pa-tients in our hospital from February 2013 to February 2014 were randomly selected and investigated, involving blood transfusion application, informed consent sign, the examination before blood transfusion, blood transfusion process re-cords, blood transfusion monitoring records, clinical assessment after blood transfusion, adverse reactions feedback of blood transfusion were compared and analyzed in the two groups. Results ①The unqualified rates of blood transfu-sion application, informed consent sign, the examination before blood transfusion, blood transfusion process records, blood transfusion monitoring records, clinical assessment after blood transfusion, adverse reactions feedback in 2014 was lower than those in 2013, but the difference had no statistical significance （P〉0.05）. The total unqualified rate of 2014 was 12.22%, significantly lower than 22.36%of 2013 （P〈0.05）.②The unqualified rate of blood transfusion re-cords of non-operation department accounted for 11.93%（65/545）, significantly lower than 20.56%（184/895） of oper-ation department （P〈0.05）.③There were adverse reactions of allergy, fever, heart failure, the bacterial contamination in blood transfusion records of 2014, which were less than those of 2013,with no statistically significant difference （P〈0.05）. The total incidence of adverse reactions of 2014 was 3.19%, significantly lower than 6.25%of 2013 （P〉0.05）. Conclusion The existing problems of clinical blood transfusion medical record should be given timely feedback and rectification work. Implementing effective management system of blood transfusion and strengthening the awareness of safe blood transfusion and related laws and regulations to medical personnel can improve the quality of blood trans-fusion records, and reduce the incidence of adverse reaction.