临床输血病历质量分析

Quality of Clinical Blood Transfusion Records

目的规范临床用血和强化输血管理，确保临床输血安全。方法回顾性分析花都区人民医院2014年6月～2015年5月随机抽取的720份临床输血病历资料，其中手术科输血病历和非手术科输血病历各360份。结果通过分析所抽取病历的整体情况，发现临床输血病历中存在输血相关记录填写不完整或不规范、无主治医生或患者家属签名确认及输血病程记录中缺少疗效评估等问题；手术科输血病历缺陷率（22．22％）显著高于非手术科的输血病历缺陷率（11．94％），差异有统计学意义（P〈0．05）。结论及时分析临床输血病历存在的问题并进行总结与整顿，实施有效可行的输血管理措施，对提高临床输血病历质量＼规范临床用血、强化输血管理以及提高临床输血安全有着积极的促进作用。

Objective To standardize clinical blood use and reinforce blood transfusion management to ensure the safety of clinical blood transfusion. Methods 720 cases of clinical blood transfusion records from Huadu People＇s Hospital during June, 2014 to May, 2015 were selected in the study, 360 records from the surgical department and another 360 ones from non - operative records. Results According to the analysis of the selected medical records, it was found that part of the records in clinical blood transfusion were not complete nor to the standard, without the doctors＇ or patients＇ family confirming signatures and lack of efficacy evaluation in the transfusion progress and etc. The defect rate of surgical department of blood transfusion records was 22.22% , significantly higher than that of non - operation with 11.94% （ P 〈 0. 05 ）. Conclusion Timely analysis, summary and rectification of the problems existing in the clinical blood transfusion records and implementa- tion of effective and feasible transfusion management measures play a positive role in the enhancement of the quality of clinical transfusion records, standardization of clinical blood use, reinforcement of blood transfusion management and improvement of clinical blood transfusion safety.