输血病历记录缺陷调查分析及对策

Investigation and Countermeasures of Blood Transfusion Record Defects

目的对临床输血病历进行调查分析,不断改进和提高输血病历书写质量。方法随机抽查我院2013~2015年临床输血病历903例,每份输血病历按《临床输血技术规范》和《医疗机构临床用血管理办法》要求进行考核。结果 2013年输血病历缺陷率为39.32%,2014年缺陷率为11.26%,2015年缺陷率为24.68%,2014年较2013年下降（P〈0.05）,2015年较2014年上升（P〈0.05）。护理记录、输血前检测、临床用血管理制度及输血会诊单这三个项目缺陷率逐年下降,输血指征控制情况缺陷率逐年上升。结论加强输血各环节管理,对输血病历存在问题进行持续性改进能有效降低输血病历的缺陷率,以避免输血纠纷发生。

Objective To investigate and analyze the clinical blood transfusion records,improve and improve the quality of transfusion records. Methods Random sampling in our hospital from 2013 to 2015,903 cases of clinical blood transfusion,each transfusion record according to the ＂clinical transfusion technical norms＂ and ＂clinical measures for the management of clinical use of blood＂ requirements for assessment. Results 2013 transfusion medical record defect rate was 39.32%,the defect rate was 11.26% in 2014,the defect rate was 24.68% in 2015,2014 decline compared to 2013（P〈0.05）,2015 rise compared to 2014（P〈0.05）. Nursing records,pre transfusion detection,clinical blood management system and blood transfusion consultation three defects rate decreased year by year,the rate of blood transfusion control defects increased year by year. Conclusion Strengthen the management of blood transfusion links,continuous improvement of the blood transfusion record problems can effectively reduce the rate of blood transfusion medical records,in order to avoid the occurrence of blood transfusion disputes.