广东省用血安全资料数字化、无纸化管理现状与思考

Reflections on the situation of digitization and paperless transfusion management in Guangdong province

目的探讨输血信息系统模式下用血安全资料、档案纸质和数字化、无纸化保存管理"双轨制"并行的可行性。方法通过走访和电话问询方式收集了广东省59家三甲医院(其中3家为新冠肺炎患者广州市定点收治医院)输血科输血信息管理系统建设、电子签名、用血安全资料纸质及数字化、无纸化管理的现况。结果所调查医院输血科均按照临床输血技术规范要求,进行用血安全纸质资料及档案管理,也开展、开发和建立了输血信息化系统:13家医院输血科实现CA电子签名;6家医院输血科实行用血安全资料、档案"双轨制"保存,按规范要求保存用血安全纸质资料的同时实现无纸化管理;广州市3家新冠肺炎定点收治医院输血科,对新冠肺炎病区送检的纸质用血申请资料严格按实验室三级防护要求消毒处理后,再按临床输血技术规范要求进行保存。结论用血安全资料、档案采取纸质和数字化、无纸化"双轨制"保存管理,是医疗机构对用血安全资料、档案实现实时监督和管理的有效措施,特别是在突发急性传染病与紧急医学救援时,可有效克服纸质资料、档案在管理过程中存在的较突出问题,发挥其在临床实践工作的作用,为用血安全全程质量控制、实现无纸化实时监督管理提供基础性支持和有效依据。

Objective To explore the feasibility of digitization and paperless management used in Blood Safety Reference Room with Transfusion Information System Mode.Methods By means of interviews and telephone inquiries,investigation was conducted on the current situation of Blood Transfusion Information Management System construction,electronic signatures,preservation of blood transfusion-related paper data and paperless management of blood using from the Transfusion Departments of 54 Class A Tertiary Hospitals in Guangdong Province(3 of which are Designated Hospitals for treating COVID-19 patients in Guangzhou).Results The Transfusion Departments of 54 Class A Tertiary Hospitals all manage blood-use safety paper documents and files according to the requirements of Clinical Blood Transfusion Technical Specifications.All hospitals have also developed and established a Blood Transfusion Information System,which have achieved the Information and Digital Management of the entire process for quality control of blood safety.The blood transfusion departments of 13 hospitals realized CA electronic signatures and the blood transfusion departments of 6 hospitals use the"dual-track system"for blood-use data archive,which can achieve the digitization and paperless management and paper document archive of blood transfusion according to the standard requirements at the same time.Transfusion Department of 3 Designated Hospitals for COVID-19 patients guaranteed the safety of blood-use for 14 patients in the COVID-19 inpatient ward from January to April 2020.The blood transfusion department strictly sterilize the blooduse application paper documents,which were submitted for inspection from the COVID-19 inpatient ward in accordance with the Laboratory Level Three Protection Requirements.Then archive the documents according to the requirements of Blood Transfusion Technical Specifications.Conclusion The Dual-Track Management for archiving paper documents and non-paper electronic data,which is related to blood-use safety,is an effective method taken by medical institutions to realize real-time supervision of safe blood using business data management.Especially in the case of acute infectious diseases and emergency medical rescue,it can effectively solve the more prominent problems in the management process of paper data and file,and make blood using business data and file management play an effective role in clinical practice.The Dual-Track Management provides basic support for realtime supervision and management of the entire process for quality control of blood safety,and provide an important and effective evidence for blood safety supervision and law enforcement management.