上海市儿童医院2017—2019年输血督查分析  

Supervision and inspection of the blood transfusion status in Shanghai Children′s Hospital from 2017 to 2019

作　　者：夏敏[1] 王淼[2] 陈莉 张泓[1] 刘永斌[2] XIA Min;WANG Miao;CHEN Li;ZHANG Hong;LIU Yongbin(Department of Clinical Laboratory,Shanghai Children's Hospital,Shanghai Jiao Tong University,Shanghai 200040,China.;Medical Department,Shanghai Children's Hospital,Shanghai Jiao Tong University,Shanghai 200040,China.)

机构地区：[1]上海市儿童医院上海交通大学附属儿童医院检验科,上海200040 [2]上海市儿童医院上海交通大学附属儿童医院医务部,上海200040

出　　处：《中国输血杂志》2020年第7期691-694,共4页Chinese Journal of Blood Transfusion

基　　金：上海交通大学中国医院发展研究院医院管理建设项目(CHDI-2018-A-19)。

摘　　要：目的通过对上海市儿童医院2017—2019年督查结果分析,以期发现问题,及时改善,保障患儿安全用血。方法 2017年1月—2019年12月对上海市儿童医院按照每季度督查1次的频率进行输血督查,督查指标包括4个主要部分:输血质量、用血评估、计划用血和输血病历质量,每次督查结果定期反馈给医务科,予以公示且提出持续改进方案。结果除运行输血专项质量监测的督查软件外,实现了输血的闭环管理,做到科学追溯;质量指标方面在出院人均用血量、手术台均用血量和急诊人均用血量等指标呈下降趋势,持续改善中;严格执行计划用血制度,每季度公布各科室计划用血情况,针对问题找出原因,采用提高自身输血、鼓励微创手术、内科纠正贫血等综合措施来做到合理用血;输血病程和同意书方面推行电子化病历,设置专门输血病程录防止漏写,重点关注输血前指征和输血后疗效评估,并与医师考核挂钩。结论定期的输血质量督查有助于输血质量的持续改进,保障输血安全。Objective To notice the problems existing in blood transfusion for children early and improve them in time,so as to safeguard the blood use for children,we analyzed the results of the supervision and inspection of the blood transfusion status in Shanghai Children′s Hospital from 2017 to 2019.Methods Inspections on blood transfusion was conducted once a quarter during a 3-year period(Jan.2017 to Dec.2019)in Shanghai Children′s Hospital,which mainly checked four monitoring indicators as:the amount of blood units transfused,blood transfusion effect,blood use plan and quality of transfusion medical records.The results of each inspection were regularly fed back to the medical department,which would been publicized and continuous improvement plans were also proposed.Results The closed-loop management of blood transfusion and scientific traceability were achieved in addition to the running of supervision and inspection software specially for blood transfusion.In terms of quality indicators,average blood consumption per inpatient been discharged,average blood consumption per operation and per capita blood consumption of Emergency Department presented downward trend and continuous improvement.The blood use plan,adherence to blood transfusion thresholds,in each department had to be announced quarterly,so the causes of the problems could be noticed early and the rational use of blood could be further improved by encouraging self-blood transfusion and minimally invasive surgery as well as correcting anemia by internal medicine etc.Electronic medical records and consent form were adopted,and special records of blood transfusion courses were set up to prevent omission.The pre-transfusion indications and post-transfusion efficacy evaluation were focused and linked with physician assessment.Conclusion Regular supervision and inspection of the quality of blood transfusion is conducive to the continuous improvement of blood transfusion quality and safeguard blood transfusion.

关 键 词：输血督查 计划用血 输血病历 闭环管理 

分 类 号：R457.1[医药卫生—治疗学]