定西市某医院不合格输血病历分析

Analysis of Medical Records of Unqualified Blood Transfusion in a Hospital in Dingxi City

目的:通过对有输血的病历分析,发现病历中存在的医疗隐患,为有针对性地进行整改,提高输血质量,促进临床科学合理用血和输血安全提供参考。方法:随机抽取某医院2013-2016年有输血的病历1875份,对病历中存在的问题进行分析。结果:在1875份病历中,不合格病历282份,不合格率为15%;其中外科病历不合格率23.9%,显著高于内科的7%。不合格病历中,知情同意书缺失、各类报告单缺失及知情同意书无家属或医师签字占82.3%,输血指征掌握不严17.7%。经过整改后的2015年,输血病历不合格率从2014年的22.1%下降到8.5%。结论:部分临床医师法律及安全意识相对薄弱,输血指征把握不严是不合格输血病历的主要问题。医院应加强对医师输血安全及相关知识的培训,提高临床合理用血水平,改进输血的病历质量,可减少医疗纠纷的发生。

Objective： Through the retrospective analysis of blood transfusion medical records, find the existence of health risks, so as to carry out rectification, promote chnical scientific and rational use of blood transfusion and blood transfusion safety. Methods： 1875 cases of blood transfusion selected randomly in a hospital from 2013 to 2016 were retrospectively analyzed. The problems existed in medical records were analyzed. Results： A total of 1875 cases, of which the unqualified medical records was 282, and the unqualified rate was 15%. The unqualified rate of surgical medical records was 23.9%, significantly higher than that of internal medicine （7%）. In unqualified records, lack of informed consent, all kinds of report and no family members or doctors informed consent signed counted 82.3%, lax blood transfusion indications counted 17.7%. After rectification in 2015, unqualified blood transfusion medical records rate significantly decreased from 22.1% in 2014 to 8.5%. Conclusion： Some clinicians＇ legal and safety awareness was relatively weak and blood transfusion indications was lax. The hospital should strengthen the training of physicians＇ blood transfusion safety and transfusion related knowledge, improve the clinical use level of blood transfusion, improve the quality of medical records of blood transfusion to reduce medical disputes.