基层医院输血延误不良事件分析及输血流程改进  

Blood transfusion delay occurred in one primary hospital and reformative measures:Case report

作　　者：冉华丽 汤荣睿[1] 胡雪 RAN Lihua;TANG Rongrui;HU Xue(The Department of Medical Laboratory,the People′s Hospital of Shapingba District,Chongqing 400030,China;Department of Blood Transfusion, the First Affiliated Hospital of Chongqing Medical University)

机构地区：[1]重庆市沙坪坝区人民医院医学检验科,重庆400030 [2]重庆医科大学附属第一医院

出　　处：《中国输血杂志》2022年第7期769-772,共4页Chinese Journal of Blood Transfusion

摘　　要：目的 分析某基层医院输血延误不良事件的根本原因,探讨改进措施,优化输血流程,保证患者输血安全。方法 回顾某基层医院输血延误不良事件,运用根本原因分析法(Root Cause Analysis,RCA)对不良事件发生原因进行研究。结果 通过RCA法挖掘出该不良事件的根本原因为:相关制度不完善、血液库存管理不合理、取血点距离远等;通过明确高危人群意外抗体筛查标本送检时间点等改进措施,将输血流程中可造成延误的环节由5处下降至1处,整改后该医院无类似输血延误不良事件发生。结论 将RCA应用于基层医院临床用血质量与安全的风险管理,可以提高医院输血安全管理风险意识,对于保障及时有效输血、避免输血延误不良事件发生起到重要的作用。Objective To reduce the occurrence of blood transfusion delay in primary hospitals,so as to optimize the transfusion process to ensure the blood transfusion safety.Methods Root cause analysis(RCA) was carried out to evaluate blood transfusion process so as to find the root causes which might affect the safety of blood transfusion.Results The root causes of this transfusion delay included imperfect transfusion regulations,unreasonable blood inventory management,long distance from the blood center,etc.By improving the time point of submitting samples,from high-risk population,for unexpected antibody screening,the links that might cause delay in the blood transfusion were reduced from 5 to 1.After rectification,no delay in blood transfusion ever occurred in the hospital.Conclusion The application of RCA in blood quality and safety management can improve the risk awareness of blood transfusion safety management,reduce the incidence of blood transfusion delay in primary hospitals.

关 键 词：根本原因分析 输血延误 不良事件 改进 

分 类 号：R457.1[医药卫生—治疗学]