2592例输血病案病程记录缺陷调查分析及持续改进

Investigation and Analysis of 2592 Cases ofTransfusion Medical Record Defects and Continuous Improvement

目的通过对某院输血病案病程记录书写情况进行抽查与结果分析,制定具有针对性的整改措施,实现病历书写的持续性改进,推进合理用血,加强临床管理,保障医疗安全。方法调取某院2018年1月1日-2019年12月31日所有输血的电子病历2592份,从输血病案输血记录的血液品种、血型、数量、输血前评估、输血后评价、有无输血记录、输血起止时间、未输血但有输血记录、输血反应上报情况等多方面对输血病程记录的规范性及完整性进行评价,并分析缺陷原因。结果共抽查电子病历2592份,输血5086次,缺陷病案631份,发生率为24.34%。2018年抽查电子病历1331份,输血2886次,缺陷病案461份,发生率为34.64%。2019年抽查电子病历1261份,输血2200次,缺陷病案170份,发生率为13.48%。缺陷病案率逐年下降,差异具有统计学意义(P<0.005)。结论通过定期检查输血病程记录的规范性及完整性,发现存在的问题并及时分析,采取确实有效的整改措施,规范病历书写,提高临床输血的安全性、合理性,在防范输血引发的医疗纠纷中起到了积极作用。

Objectives Through the random check and analysis of the writing status of the blood transfusion medical history records in our hospital,develop targeted rectification measures to achieve continuous improvement of medical record writing,promote clinical science and rational use of blood,and ensure clinical blood use.On the basis of quality,it also provided a strong guarantee for medical safety.Methods A random sample of 2592 electronic medical records of our hospital from January 2018 to December 2019 was taken from the hospital.Blood types,numbers,pre-transfusion evaluation,post-transfusion evaluation,blood transfusion records,and blood transfusions were recorded from the blood transfusion history records.Evaluation of start and end time,no blood transfusion but with blood transfusion record,and report of transfusion reaction,etc,and the problems existing in the course of writing were summarized,and the reasons were analyzed.Results From 2018 to 2019,a total of 2592 electronic medical records were sampled,5086 blood transfusions were performed,and 631 were defective medical records,of which 24.34%were defective medical records.In 2018,a total of 1,331 electronic medical records were sampled and 2,886 blood transfusions were performed,of which 461 were defective medical records,accounting for 34.64%of the defective medical records.In 2019,a total of 1261 electronic medical records were sampled and 2,200 blood transfusions were performed,including 170 defective medical records,which accounted for 13.48%of the defective medical records.The defect medical record rate from 2018 to 2019 has been decreasing year by year.Compared with 2018,the difference was statistically significant(P<0.005).Conclusions By regularly checking the writing specifications of clinical transfusion medical records,discovering problems and analyzing them in a timely manner,and adopting effective rectification measures to regulate the writing of medical records,thereby improving the safety and rationality of clinical blood transfusion and preventing medical disputes caused by blood transfusion positive effects.