HIMSS7-PDCA信息化管理在临床输血病案质控中的应用  

Application of HIMSS7-PDCA Information Management in Quality Control of Clinical Blood Transfusion Medical Records

作　　者：张洪红 王妮娜 王凯 高雷 李丹华 刘荣 陈昊阳 孙福廷 Zhang Honghong;Wang Nina;Wang Kai;Gao Lei;Li Danhua;Liu Rong;Chen Haoyang;Sun Futing(Department of Blood Transfusion,Sunshine Union Hospital,Weifang 261041,Shandong Province,China)

机构地区：[1]阳光融和医院输血科,山东省潍坊市261041

出　　处：《中国病案》2025年第1期13-16,112,共5页Chinese Medical Record

基　　金：山东省潍坊市卫生健康委员会项目(WFWSJK-2022-180)。

摘　　要：目的探讨HIMSS7信息化体系结合PDCA循环在临床输血病案质量持续改进中的应用效果,促进输血病案规范化管理,保障医疗安全。方法收集某院2021年9月1日-2022年8月31日3605份输血病案作为对照组,以2022年9月1日-2023年6月30日3708份输血病案为实验组,对照组对输血病案采用传统管理,实验组对输血病案进行HIMSS7信息化体系下的PDCA循环管理,通过计划阶段分析病案不合格的原因,根据PDCA改进需求,全面整合医院信息系统,构建和完善HIMSS7标准下的输血闭环管理系统,全面实现对临床用血和输血病案全流程的节点监管。结果PDCA循环法联合HIMSS7信息化改进措施实施后临床输血病案合格率由80.7%提升到90.6%(P<0.01);输血文书记录规范率由88.2%上升至94.2%(P<0.01);输血指征符合率由原来的92.6%上升到96.4%(P<0.01);48小时内输血文书不规范记录整改率由66.4%提升到82.2%(P<0.01);48小时内大量用血及时审批率由原来的54.3%提高到80.6%(P<0.05),输血病案质量得到有效提升。结论HIMSS7-PDCA信息化质量持续改进可有效提升临床输血病案质量,使输血病案更加标准化和规范化,提高了临床输血的安全性和及时性。Objectives This study aims to explore the application effect of HIMSS 7 information system combined with PDCA cycle in continuous improvement of clinical transfusion medical record quality, so as to facilitate the standardized management of transfusion medical records and ensure patient safety. Methods 3,605 blood transfusion case records from a certain hospital from September 1, 2021 to August 31, 2022 were collected as the control group,and 3,708 blood transfusion case records from September 1, 2022 to June 30, 2023 were collected as the experimental group. The control group manages blood transfusion case records adopted traditional methods, while the experimental group manages blood transfusion case records adopted the HIMSS7 information system-based PDCA cycle management. By analyzing the causes of non-compliance in medical records during the planning phase and addressing improvement needs based on the PDCA cycle, the hospital information system was comprehensively integrated to build and enhance a closed-loop blood transfusion management system in accordance with HIMSS7standards. This fully enables node-based supervision of the entire clinical blood usage and transfusion record process. Results After the implementation of the PDCA cycle method combined with HIMSS7 information technology improvement measures, the qualification rate of clinical transfusion medical records increased from 80.7% to 90.6%(P<0.01). The standardization rate of blood transfusion documentation increased from 88.2% to 94.2%(P<0.01). The compliance rate of transfusion indications increased from 92.6% to 96.4%(P<0.01). The rectification rate of non-standard blood transfusion documents within 48 hours increased from 66.4% to 82.2%(P<0.01). The timely approval rate for large-scale blood transfusion within 48 hours has increased from 54.3% to 80.6%(P<0.05), and the quality of blood transfusion medical records has been effectively improved.Conclusions The continuous improvement of HIMSS7-PDCA information quality can effectively improve the q

关 键 词：HIMSS7 PDCA循环 信息化管理 临床输血病案 

分 类 号：R197.323[医药卫生—卫生事业管理]