861份临床输血病历质量调查分析

Transfusion treatment quality analysis based on 861 documented patients

目的:通过督查输血病历质量,分析存在问题,规范临床用血。方法:随机抽查某院2018年-2019年共计861份输血病历。从输血前评估、输血前检查、输血医嘱、输血知情同意书、输血记录、输血疗效的评估6个方面进行回顾性分析和比较。结果:2019年的输血病历合理率比2018年显著增加,差异有统计学意义(P=0.0178);输血病历各检查项目不合理率对比可见,与2018年相比较,2019年输血前的评估不合理率显著增加,差异有统计学意义(P=0.0067);输血记录不合格率升高。输血后疗效评估的不合格率升高,差异无统计学意义(P=0.0761)。结论:分析输血病历中不合格的原因,提出建议,规范临床科学合理用血并提高输血病历质量。

Objective:To improve the quality of the transfusion record documentation by analyzing the current records.We also hope the data would provide valuable reference data to minimize potential medical incidents.Methods:A Retro-spective analysis with 6 preset parameters were conducted on a random sample pool of 861 blood transfusion patients in our hospital recorded from 2018 to 2019.The presets included pre-transfusion assessment,pre-transfusion tests,transfusion medical advice,physician transfusion record integrity informed consent for transfusion therapy,post-transfusion assessment.Results:Compared with 2018,the total pass rate of blood transfusion records in 2019 increased significantly,with.Statistically significant(P=0.0178).In 2018 and 2019,the unqualified rate of each examination item in the blood transfusion medical record was compared.Compared with 2018,the unqualified rate of the pre-transfusion assessment was significantly increased (P=0.0067).It’s statistically significant.The unqualified rate of blood transfusion records increased,without statistical significance(P=0.0888).The post-transfusion assessment was increased.There was no statistical significance(P=0.0761).Conclusion:To improve clinical record documentation,We analyzed the causes of the disqualification in the medical records of blood transfusion and put forward Suggestions to standardize the clinical,scientific and rational use of blood.