2014年-2017年临床输血病案质量调查与分析

Survey and Analysis of the Quality of Clinical Transfusion Records from 2014 to 2017

目的通过回顾性分析某院临床输血病案质量,总结管理方案,提出改进措施,提高输血管理水平,保障临床科学合理用血。方法自2012年起,某院输血科每月对全院输血病案进行检查,督导临床科学合理输血。现回顾性分析2014年1月1日至2017年12月31日某院临床输血病案8155份。统计分析输血前检查、知情同意书(和/或授权委托书)、输血申请单、输血适应症、输血医嘱、输血核查记录单、输血病程记录、输血后检查、输血后评估记录等病案检查项目,记录不合格病案例数。运用SPSS15.0对输血病案不合格率进行统计分析,P<0.05表示差异有统计学意义。结果 8155份输血病案中有1020份不合格病案,不合理率为12.5%。2014年至2016年病案不合格率逐年下降,且差异有统计学意义P<0.05,2017年不合格率变化无统计学差异。其中输血知情同意书,输血医嘱,输血记录和输血后评估记录不合格率较高。结论每月对临床输血病案进行核查与督导可有效提高临床输血病案质量。

Objective By retrospectively analyzing the quality of clinical transfusion medical records in a hospital, summarizing the management plan, proposing improvement measures, improving the level of blood transfusion management, and ensuring the scientific and rational use of blood. Methods Since 2012, the Blood Transfusion Department of a hospital has been conducting monthly inspections on blood transfusion records in the hospital and supervising the clinicians＇ scientific and reasonable blood transfusions. A retrospective analysis of 8155 cases of clinical blood transfusion in the hospital from January 1, 2014 to December 31, 2017 was conducted. Statistical analysis of pre-transfusion examination, informed consent forms （and/or power of attorney）, blood transfusion application forms, blood transfusion indications, blood transfusion orders, blood transfusion check sheets, transfusion history records, post-transfusion examinations, post-transfusion evaluation records, and other medical examination items, recording the number of unqualified cases. SPSS15.0 was used to statistically analyze the failure rate of transfusion cases. P〈0.05 indicated that the difference was statistically significant. Results There were 1,020 unqualified medical records in the 8155 blood transfusion cases, and the unreasonable rate was 12.5%. From 2014 to 2016, the rate of unqualified medical records decreased year by year and the difference was significant at P〈0.05. There was no significant difference in the rate of disqualification in 2017. Among them, the disqualification rates of blood transfusion informed consent, blood transfusion orders, blood transfusion records, and post-transfusion evaluation records were high. Conclusion Monthly verification and supervision of clinical blood transfusion cases can effectively improve the quality of clinical blood transfusion cases.