2013年-2015年输血病案调查分析

Investigation and Analysis of Blood Transfusion Medical Record from 2013 to 2015

目的调查分析输血病案书写情况,以便更好落实、改进医院输血病案质量管理措施,提高临床输血质量;保障输血安全。方法回顾性调查2013年-2015年91份临床输血病案,对调查结果进行分析。结果 2015年与2013年相比,病案首页不合格率下降幅度最大85.7%、知情同意书、输血前检查、输血病程记录、输血护理记录、输血记录单、出院记录不合格率降幅分别是-7.4%、14.1%、-1.4%、20.3%、37.9%、25%。结论输血病案书写质量管理有一定效果,但在输血病案书写规范性、完整性方面仍存在很大问题,主管部门应加强培训和督导,以持续改进输血病案书写质量,确保输血安全,减少输血医疗纠纷的发生。

Objective To research and analyze blood transfusion medical record writing situation, in order to better implement and improve the hospital transfusion medical record quality management measures, improve the quality of clinical blood transfusion. Make blood transfusion safety. Methods A total of 91 cases of clinical blood transfusion medical records from 2013 to 2015 were retrospectively surveyed and analyzed. Results Compared with 2013, the Unqualified rate of medical record home page in 2015 has the maximum decrease which reached 85.7%.The failure rate of informed consent, inspection before blood transfusion, blood transfusion duration course record,blood transfusion nursing records, blood transfusions Record, discharge summary record were-7.4%, 7.4%,-1.4%, 20.3%, 37.9%, 25%. Conclusion The blood transfusion medical record writing quality management has a certain effect, but in the blood transfusion medical record writing standardization, integrity, there is still a great problem. Departments should strengthen the training and supervising, continue to improve blood transfusion medical record writing quality, ensure transfusion safety, reduce the occurrence of blood transfusion medical disputes.