临床输血病历质量分析与探讨  

Analysis and Discussion on the Quality of Medical Records in Clinical Transfusion

作　　者：王敏[1] 潘健[1] 姚萍[1] 完晓菊[1] 周明[1] 蒋光明[1] 廖艳秋[1] 应美爱[1] 周建华[1] 朱梅红[1] 王丹[1] 李娟[1] 张媛媛[1] 李寅坤 

机构地区：[1]安徽医科大学附属省立医院,合肥230001

出　　处：《临床输血与检验》2016年第4期329-333,共5页Journal of Clinical Transfusion and Laboratory Medicine

摘　　要：目的通过加强临床输血病历监管,提高输血病历质量,促进临床科学、合理用血,降低输血所致医疗纠纷风险。方法每月随机抽检本院手术科室、非手术科室输血病历共50份,依据《医疗机构临床用血管理办法》、《临床输血技术规范》及《安徽省立医院临床用血管理暂行规定》进行分析、总结,并通过医务处向全院通报。结果 2011~2015年共抽查输血病历3 000份,手术科室、非手术科室组各1 500份,其输血病历质量不合格例数及不合格率分别为：252（8.4%）、147（4.9%）;2011~2015年临床输血病历不合格率逐年降低,分别为22.5%、18.33%、12.67%、9.67%、3.33%。结论输血病历及输血过程的标准化是临床输血科学、安全、合理、有效的重要保障。Objective By means of strengthening standardized management of medical records for clinical blood transfusion, improving the quality of medical records and promoting the reasonable use of blood and reduce medical tangle caused by the clinical usage of blood. Methods ＂Clinical blood transfusion technical specifications＂, ＂Medical institution clinical blood management approach＂ and ＂Temporary rules of Clinical blood transfusion technical specifications of Affiliated Provincial Hospital of Anhui Medical University＂ were used as the main basis for the study. 50 cases were randomly selected from the medical and surgical operation records monthly. Results 3000 hospitalized patients with transfusion records were randomly selected from 2011 to 2015. The number and percentage of defective clinical transfusion medical records were 252（8.4%） and 147（4.9%）, respectively. The percentage of defective clinical transfusion medical records decreased by year from 2011 to 2015. The results were 22.5%, 18.33%, 12.67%, 9.67%, 3.33%, respectively. Conclusions Standardized blood transfusion medical records and process are important guaranties for scientific, safe, reasonable and effective blood transfusion.

关 键 词：输血病历 医疗纠纷 合理用血 

分 类 号：R457.12[医药卫生—治疗学]