临床输血病历质量检查结果与分析  

Results and analysis of clinical blood transfusion medical records quality inspection

作　　者：沈建梅 SHEN Jianmei(Department of Clinical Laboratory,Taizhou Fourth People’s Hospital,Taizhou,Jiangsu 225399,China)

机构地区：[1]泰州市第四人民医院检验科,江苏泰州225399

出　　处：《医药前沿》2023年第23期5-8,共4页Journal of Frontiers of Medicine

摘　　要：目的:分析定期检查临床输血病历的效果,以提高临床输血病历质量,促进合理用血。方法:回顾性随机调取泰州市第四人民医院2021年1—6月每月10份患者的归档输血病历,其中每月内外科各5份,连续6个月,共计60份。从2022年1月开始定期检查临床输血病历并及时反馈,针对存在的问题进行相关知识培训,要求临床科室不断整改。于2022年1—6月每月末随机抽取10份住院患者的临床输血病历,其中内科和外科各5份,连续6个月,共计60份。采用自制“输血管理调查表”评价同期输血案例质量。结果:2022年1—6月输血病历合格率(85.00%)高于2021年1—6月输血病历合格率(68.33%),差异有统计学意义(P<0.05);内科临床输血病历合格率为93.33%,高于外科临床输血病历合格率(76.67%),差异有统计学意义(P<0.05);对2022年1—6月60份临床输血病历缺陷项目进行统计,查验项目例次共490条,其中缺陷项目例次共73条,占比为14.90%。缺陷率排名前3位的项目为输血医嘱和病历(38.33%)、用血后疗效评价(23.53%)和输血前评估(19.61%)。外科缺陷项目共51例次,占比69.86%;内科缺陷项目共22例次,占比30.14%;在检查临床输血病历中发现,外科输血病历在输血前评估以及用血后疗效评价方面缺陷率均高于内科。结论:不间断的定期检查临床输血病历,可以激励医生不断完善输血病历,提高临床输血病历质量,规范合理用血。Objective To analyze the effect of regular examination of clinical blood transfusion records in order to improve the quality of clinical blood transfusion records and promote rational use of blood.Methods The archived blood transfusion medical records of 10 patients per month in Taizhou Fourth People’s Hospital from January to June 2021 were randomly selected,including 5 in each department of medicine and surgery per month for 6 consecutive months,with a total of 60 records.From January 2022,our hospital began to regularly check clinical blood transfusion records and give timely feedback,conduct relevant knowledge training for existing problems,and require clinical departments to continuously improve.Clinical blood transfusion medical records of 10 inpatients in our hospital were randomly selected at the end of each month from January to June 2022,including 5 medical records and 5 surgical records for 6 consecutive months,with a total of 60 records.Blood transfusion management questionnaire was used to evaluate the quality of transfusion cases in the same period.Results The qualified rate of blood transfusion medical records from January to June 2022(85.00%)was higher than that from January to June 2021(68.33%),and the difference was statistically significant(P<0.05).The qualified rate of medical blood transfusion records was 93.33%,higher than that of surgical blood transfusion records(76.67%),and the difference was statistically significant(P<0.05).Defects in 60 clinical blood transfusion medical records from January to June 2022 were counted,and a total of 490 cases were checked,of which 73 were defective,accounting for 14.90%.The top 3 items in terms of defect rate were transfusion doctor’s order and medical record(38.33%),posttransfusion efficacy evaluation(23.53%)and pre-transfusion evaluation(19.61%).There were 51 cases of surgical defects,accounting for 69.86%.There were 22 cases of defects in internal medicine,accounting for 30.14%.In the examination of clinical blood transfusion records,it was found

关 键 词：输血病历 输血前评估 合理用血 质量评价 

分 类 号：R826.2[医药卫生—临床医学]