900份临床输血病历合理性调查分析

Investigation and analysis of rationality of 900 cases of clinical blood transfusion

目的调查医院输血病历中存在的问题,分析不合理因素,不断提高临床输血质量。方法从本院2016年1月-2017年1月有输血治疗的病历中,依据住院号利用随机数字表法随机抽取900份,调查每份输血病历中输血有关记录完整性,依据《临床输血技术规范》中"手术及创伤输血指南"及"内科输血指南"结合患者体征,对常见成分血如红细胞、血浆、及冷沉淀等输注合理性进行评价。结果抽取的病历中手术科室583份,非手术科室317;手术科室与非手术科室临床输血病历合理率存在差异,非手术科室的合理率高于手术科室(χ~2=7.723,P=0.021),非手术科室合理率为93.8%,而手术科室仅为88.0%;900份输血病历中4种血液成分输注合理性差异具有统计学意义(χ~2=214.767,P<0.001)。非手术科室红细胞、血浆、冷沉淀合理率高于手术科室;900份病历中有55份记录不合格,主要是输血后评估不全、未记录输血反应。手术科室与非手术科室临床输血病历相关记录不合格率差异具有统计学意义(χ~2=4.613,P=0.032)。结论部分医师掌握输血适应证欠佳,对于用血前评估及输血后疗效评价重视不足,存在输血不合理,且以手术科室明显,不重视输血病历书写,医院应加强输血管理不断提高输血的科学性、规范性。

Objective To investigate the problems existing in hospital transfusion records, analyze unreasonable factors, and improve the quality of blood transfusion.Methods Investigation of our hospital from January 2016 to January 2017 with blood transfusion medical records, according to hospitalization number,900 cases were selected, using random number table. Investigating blood transfusion records on each record integrity, according to ＂ Guidelines for Surgical and Traumatic Blood Transfusion＂ and ＂Internal medicine transfusion guide＂ in＂ clinical blood transfusion technical specifications＂ . The common blood components such as red blood cells, plasma and cryoprecipitate infusion and rationality evaluation. Results There were 583 surgical departments and 557 non-surgical departments. There was a significant difference between the surgical department and the non-surgical department. The reasonable rate of non-operation department was higher than that of the operation department （X2= 7. 723, P= 0. 021 ） .The rational rate of the department was 93.8%, while the operation department was only 88.0% ; 900 blood transfusion records of four kinds of blood components of the rationality of the difference was statistically significant （X2 =214. 767, P〈0. 001）. Non-surgical department of erythrocyte, plasma, cold precipitate reasonable rate than the surgical department; 900 medical records in 55 records failed, mainly after the assessment of incomplete blood transfusion, no recorded blood transfusion reaction. There were significant differences in the failure rate between the surgical department and the non-surgical department （X2 =4. 613, P=0. 032） .Conclusion Some physicians transfusion indications, for evaluation before and after blood transfusion blood insufficient attention to curative effect evaluation, blood transfusion is not reasonable, and in the operation department, do not take the blood transfusion medical record writing, hospitals should strengthen the blood transfusion blood transfusion continuously improve the scientific and normative management.