一级医院155份输血病案质量分析

Quality Analysis of 155 Blood Transfusion Medical Records in First Class Hospitals

目的通过对一级医院155份输血病案进行质量分析,以掌握其安全科学合理输血及输血管理现状,为规范输血管理提供依据。方法对某市12家开展输血业务的一级医院2016年-2018年155份输血病案质量进行统计分析。结果住院病案首页不合格率29.0%,输血治疗同意书不合格率43.2%,输血前检查不合格率15.5%,输血前评估不合格率52.2%,输血指征不合格率22.6%,输血过程记录不合格率27.1%,输血后疗效评价不合格率81.3%,输血护理记录不合格率61.3%,发血报告单不合格率5.2%。结论一级医院输血管理和临床科学合理输血水平均亟待提高。

Objective Totally 155 blood transfusion medical records in first class hospitals are analyzed to master their current situation of safe,scientific and reasonable blood transfusion and blood transfusion management,and to provide a standardizing blood transfusion management.Methods 155 blood transfusion medical records from 2016 to 2018 in 12 first-class hospitals of a certain city which carry out blood transfusion business are Statistically analyzed.Results The unqualified rate of the front page of the medical records was 29.0%,the consent for transfusion treatment 43.2%,the before-transfusion examination 15.5%,the before-transfusion evaluation 52.2%,the transfusion indication 22.6%,the transfusion process record 27.1%,the post-transfusion curative effect evaluation81.3%,the transfusion nursing record 61.3%,and the bloodletting report 5.2%.Conclusion The management of blood transfusion in the first-class hospitals and the reasonable level of blood transfusion in clinical sciences needs to be improved urgently.