肿瘤专科医院输血病历质量缺陷分析及管理建议

An analysis and management suggestions of blood transfusion medical record quality defects in tumor hospital

目的分析输血病历质量缺陷,全方位梳理管理措施,提出管理建议,改进输血病历质量。方法总结医院2019年度质控输血病历时发现的输血病历质量缺陷,详细分析缺陷原因,有针对性地提出改进措施。结果输血病历质量缺陷主要在首页、输血前检查、输血前评价、知情同意书、申请审批单、输血记录、医嘱、输血后评价等方面,其中以输血前评价和输血记录问题较多。结论输血病历质量的管理是医院、职能部门、医师个人相互配合、相互协作的过程,缺一不可。有针对性地从医院层面、职能科室层面和医师层面三个方面提出的管理建议,能进一步提高输血病历质量。

Objective To improve the quality of blood transfusion medical records by analyzing the quality defects of blood transfusion medical records,comprehensively sorting out the management measures,and putting forward management suggestions.Methods The quality defects of blood transfusion cases in the hospital during the period of quality control transfusion disease in 2019 were summarized,the causes of the defects were analyzed in detail,and the improvement measures were proposed.Results The quality defects of blood transfusion medical records were mainly in the front page,pre-transfusion examination,pre-transfusion evaluation,informed consent,application approval form,blood transfusion records,medical advice and post-transfusion evaluation,among which the pre-transfusion evaluation and blood transfusion records were more problematic.Conclusion The management of the quality of blood transfusion medical records is a process of mutual cooperation between hospital,functional departments and individual doctors,each of which is indispensable.Targeted management suggestions from hospital level,functional department level and physician level can further improve the quality of blood transfusion medical records.