临床用血申请分级管理制度实施与效果评价  

Implementation and Effectiveness Analysis of the Classification Management System of Application for Clinical Blood Transfusion

作　　者：庄健美[1] 谈春荣[1] 于文娟[1] 张金荣[1] 唐丽珍[1] 陈岩[1] 翟月萌 何欣[1] 

机构地区：[1]首都医科大学附属北京世纪坛医院,北京100038

出　　处：《临床输血与检验》2016年第3期220-223,共4页Journal of Clinical Transfusion and Laboratory Medicine

摘　　要：目的实施新的临床用血申请分级管理制度，评价临床用血申请分级审核的监管效果。方法对2013年7月～2014年6月5476张临床用血申请单进行质量审核，按照PDCA循环原理重新修订和实施医院临床用血申请分级管理制度，HIS系统建立主治或以上专业技术职称医师开具临床用血电子申请自动授权管理，输血科建立临床用血申请单全面质量审核及实时记录，定期统计分析、上报、公示临床用血申请分级审核签字情况，实施全医院临床用血申请分级管理的综合质量目标控制。结果临床用血申请上级医师审核签字合格率大于96．97％；临床用血申请单科主任审核签字合格比例由22．97％上升到95．00％（P〈0．01）；医务处审核签字合格率由88．00％上升到95．00％。结论执行新的临床用血申请分级管理制度可显著改善质量，有利于临床合理用血水平的提高。Objective To implement the classification management system of application for clinical blood transfusion and evaluate its effects on audit supervision. Methods Processing qualification verification on the 5476 pieces of application for clinical blood transfusion which were audited during July, 2013 to June, 2014. Then revising and implementing the classification management system of the application for clinical blood transfusion according to the PDCA circulation principle. The HIS＇ s automatic authorization to the titles of attending physicians or above was used for prescribing electronic applications of blood transfusion. The institution of comprehensive quality audit and real-time records were established in blood transfusion rooms. There were regular statistical analysis, reporting and announcement of the results of the audit supervision. The comprehensive quality control to the classification management system of the application for clinical blood transfusion was carried out in the hospital. Results The average qualification rate of the application that needs to be examined and be signed by the senior doctors surpassed 96.97%. The average qualification rate of the application submitted to the director increased from 22.97% to 95%（P 〈 0.01） and by staff of Medical Department from 88% to 95% simultaneously. Conclusion The implementation of classification management system of application for clinical blood transfusion obviously improved the quality of application, promoting the appropriate clinical use of blood products.

关 键 词：输血 临床用血申请分级管理 质量监管 

分 类 号：R457.1[医药卫生—治疗学]