1511份临床输血病历输血相关记录规范性调查分析

Analysis on standardization of 1 511 clinical blood transfusion medical records

目的通过调查了解医院输血过程和相关原始记录,进一步规范医护人员输血行为和输血相关记录,促进医院输血病历的规范管理。方法按照临床输血相关国家法规和标准[1],对2013年本辖区九家医院输血病历1 511份逐一进行评价、统计和分析。结果输血治疗同意书、输血申请、输血医嘱、配血发血记录、输血护理记录、手术室输血记录、输血疗效评价、输血病程记录不规范比例分别为13.37%、12.51%、6.82%、15.62%、32.96%、8.14%、20.25%、25.28%。结论今后应加强对医护人员的培训和输血过程的管理,保证输血相关记录规范和输血安全。

Objectives To further standardize the blood transfusion practice and records among clinical medical staff and to improve the canonical management of transfusion medical records through investigating blood transfusion process and related records. Methods In accordance with the relevant state laws and regulations of clinical blood transfusion and standards,a total of 1 511 blood transfusion records from 9 hospitals in our district were evaluated and analyzed. Results The proportions for unstandardized practice and management were 13. 37%,12. 51%,6. 82%,15. 62%,32. 96%,8. 14%,20. 25% and 25. 28% for informed consent in blood transfusion,transfusion proposal,doctor＇s advice,blood crossmatch and assignment,transfusion nursing records,transfusion records from operating room,transfusion effect evaluation,and process records,respectively. Conclusion Training for clinical medical staff and management for transfusion process should be strengthened in order to guarantee the safety of transfusion and standardized transfusion records.