某部中心医院输血病历质量调查分析

Quality Analysis of Blood Transfusion Records in a Central Hospital

目的探讨医院输血病历中存在的问题,采取改进措施提高临床输血病历质量。方法调查某院2012年1月-2013年6月324份输血病历,按医院等级评审细则"输血管理与持续改进"要求拟调查表,调查评估时逐一分类填写,最后统计分析。结果调查发现输血前使用抗过敏药203例(62.7%),输血治疗前指征掌握过宽63例(19.4%),输血后无疗效评估100例(30.9%),输血病程记录不合格96例(29.6%),出院病历首页记录不全90例(27.8%),输血治疗同意书填写不全48例(14.8%);212份内外科病历存在的主要问题是无输血治疗过程记录、无输血护理记录、无输血适应证等,成分输血存在的主要问题是用血次数多、用血适应证偏宽。输血病历甲级率为20.1%,乙级率61.1%,丙级率18.8%。结论临床医师掌握输血指征欠佳,存在输血不合理、输血后无评估,不重视输血病历书写,以及输血前普遍存在使用抗过敏药等问题,应引起临床医师及医院质管人员的高度重视。

Objective To investigate the existing problems with transfusion records and suggest measures to improve the quality of clinical transfusion records. Methods A total of 324 transfusion records in a hospital from January 2012 to June 2013 were surveyed by a questionaire designed with hospital grade assessment rules of ' blood transfusion management and continuous improvement'. After each category of investigation and assessment was filled in,the final results were statistically analyzed. Results The problems with transfusion records included the use of anti-allergy drugs in 203 patients( 62.7%),too wide a range transfusion indications in 63 cases( 19.4%),lack of assessment of the therapeutic value in 100 patients( 30.9%) after transfusion,96 cases( 29.6%) of unqualified records,90 cases( 27.8%) of incomplete discharge records,and 48 cases( 14.8%) of incomplete blood transfusion consent.The main problems with the 212 records were the lack of records of transfusion treatment and nursing care,and the absence of transfusion indications.The main problem with blood component transfusion was frequent transfusion and an excessively wide range of blood indications. The rate of grade A transfusion medical records was 20.1%,61. 1% for grade B,and 18.8% for grade C. Conclusion Clinicians’ poor knowledge of transfusion indications,unreasonable use of transfusion,no assessment of blood transfusion,unqualified blood transfusion medical records and wide use of allergy medication before blood transfusion should be a concern of clinicians and quality control personnel in a hospital.