医院输血全面信息化改进的分析  

Analysis on improvement of hospital blood transfusion comprehensive informatization

作　　者：张宇[1] 陈会欣[1] 王顺[1] 

机构地区：[1]武汉市第一医院输血科,武汉430022

出　　处：《临床血液学杂志（输血与检验）》2016年第6期959-961,共3页Journal of Clinical Hematology(Blood Transfusion & Laboratory Medicine)

基　　金：武汉市卫生计生委医疗卫生科研资助项目(No:WG13C20);湖北省卫生计生采供血专项资助项目(No:WJ2015CB006)

摘　　要：目的:了解HIS系统输血模块的启用与改进对输血文档填写质量的作用,确保临床科学、合理、规范化安全输血[1]。方法:回顾性分析武汉市第一医院2012-05-2012-10共计3 347份输血申请单,按HIS系统输血模块少部分科室启用,HIS系统输血模块全面启用但未对临床培训及HIS系统输血模块全面启用且对临床培训后分为部分启用组,未培训组,培训组,分别对各组的电子申请单覆盖率及文档填写质量进行相关分析,评价医院输血管理系统的启用后和经过输血科培训后各科室文档电子化的覆盖及输血申请单质量情况。结果:HIS系统输血模块上线后,电子输血申请单覆盖率由18.09%升至49.17%,经过输血科培训后电子输血申请单上升至78.4%;输血申请单合格率由51.7%升至81.40%,经过输血科培训后合格率升至93.0%,两者呈现正相关关系(R=0.99)。研究发现输血申请单的合格率上升主要是由于电子病历的推广所导致的。结论:随着HIS系统输血模块的上线,输血申请单逐步电子化,不合格率也逐步降低,有助于进一步规范输血、用血安全,减少输血医疗纠纷。Objective：To comprehend the importance of using and improving the blood transfusion module of HIS system for the transfusion documents,and to ensure the scientific,reasonable,standardized and safe clinical blood transfusion.Method：A total of 3 347 cases of transfusion requisition forms from May to October in 2012 were retrospectively analyzed,and divided into three groups：partly using group,untrained group and trained group,according to the following criteria：partly using the module,officially using with no clinical training and officially using with clinical training.The electronic coverage rate of these forms and the validity of these documents were analyzed,as well as the rate and the validity were evaluated in each department after the hospital starting using the management system and Transfusion Department＇s training.Result：When the HIS system module getting on-line,the electronic coverage rate of these forms increased from 18.09%to 49.17%,and the data had gone up to 78.4% after the training;while the qualified rate of these forms rose up to 81.40%from 51.7%,and ascended to 93.0% after the training,which showed a positive correlation（R=0.99）.The study revealed that the rise of qualified rate of the transfusion requisition forms was mainly associated with the promotion and spread of electronic medical record.Conclusion：With the on-line process of blood transfusion module of HIS system and the blood transfusion requisition forms becoming gradually electronic,the unqualified rate is increasingly reduced,which would contribute to further regulating the blood transfusion and using blood with safety while reducing medical disputes.

关 键 词：输血申请单 电子病历 HIS系统 手写病历 电子申请单覆盖率 

分 类 号：R457.1[医药卫生—治疗学]