某市输血病案质量考评促进科学合理用血

To Promote Scientific and Rational Use of Blood by Blood Transfusion Medical Quality Evaluation in a City

目的通过输血病历考评,促进某市科学、合理用血,节约血源。方法通过对2013年-2015年输血病历中输血适应症、输血申请、输血记录、输血疗效评价四大方面进行检查,其中输血适应症主要查看其合理性,输血申请、输血记录、输血疗效评价主要查看其相关文书记录是否规范、完整。分别对扣分病案次数、每月平均分及合格率进行分析。结果不合理用血占比2014年5.76%较2013年14.64%明显下降,2015年较2014年变化不明显,主要是血浆及冷沉淀的不合理输注,其中血浆由52.41%下降至27.59%,冷沉淀由24.24%下降至3.7%;输血申请、输血记录、输血疗效评价等相关文书记录扣分病案占比逐年下降。2014年每月考评平均分最高,2015年前6月平均分较低,后6月平均分接近2014年平均分,最后一月平均分较2014年高,高达94.75。每月合格率变化趋势与平均分相同,最后一个月合格率高达96.12%。结论由近3年考评结果可知:输血病案考评能促进合理用血,规范文书书写,推进病案质量持续改进,保障医疗安全。

Objective Through the evaluation of blood transfusion records, to promote a scientific and rational use of blood, save the blood. Methods We checked four aspects of transfusion indications, blood transfusion applications, record of the transfusion and transfusion efficacy evaluation in transfusion records from 2013 to 2015. The indications of transfusion mainly was checked depending on its rationality. The transfusion application, record of transfusion and transfusion efficacy evaluation were mainly related with the record of complete and standard. The number of points of medical records, monthly average and pass rate were analyzed respectively. Results The unreasonable use of blood of 5.76% in 2014 decreased significantly compared to 14. 64% in 2013, but there was no obvious change between 2014 and 2015. There were mainly the plasma and the cold precipitation of unreasonable infusion, in which the plasma decrease from 52. 41% to 27. 59% and the cold precipitation decrease from 24. 24% to 3.7%. The proportion of medical record points of transfusion application, the record of the transfusion, blood transfusion efficacy evaluation decreased year by year. The monthly average was the highest score in 2014. The first six months average were the lowest in 2015, but the average score got close to 2014 later. The average of the final month was higher than average of 2014, up to 94. 75. The monthly pass rate change trend is the same as the average, the last up to 96. 12%. Conclusion From the evaluation results of the past 3 years, evaluation of transfusion records promotes rational use of blood and specification of writing instruments. It also promotes improvement of medical record quality continuously and ensures medical safety.