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临床输血与检验

临床输血与检验 ›› 2017, Vol. 19 ›› Issue (3): 237-239.DOI: 10.3969/j.issn.1671-2587.2017.03.008

• 临床输血 • 上一篇    下一篇

皖北某地31家医院临床输血病历的评价情况分析

孙友岭, 李涛, 徐晶晶, 周涛, 万胜全   

  1. 232007 安徽省淮南市中心血站（淮南市临床用血质控中心）
  • 收稿日期:2017-01-24 出版日期:2017-06-20 发布日期:2017-06-23
  • 作者简介:孙友岭（1969-）,男,安徽凤台人,副主任技师,学士,主要从事血液检验工作,（E-mail）495674131@qq.com.

Basic Evaluation Analysis of 31 Medical Records of Clinical Blood Transfusion in Northern Anhui

SUN You-ling, LI Tao, XU Jin-jin, et al   

  1. Huainan Municipal Center Blood Station,Huainan Clinical Center of Blood Quality Control,Huainan,232007
  • Received:2017-01-24 Online:2017-06-20 Published:2017-06-23

PDF

817

被引次数

3

摘要： 目的 通过对临床输血病历的评价,了解临床输血的薄弱环节。方法 抽取全市临床用血31家医院的输血病例148份,对输血病历的书写内容、用血医嘱情况、输血前检查结果、输血申请、输血知情同意书、输血病程记录、输血过程记录、输血适应证的掌握情况、成分输血率及红细胞使用率进行评价。结果 未见输血史或妊娠史描述为71%、输注血液品种书写错误为3%、交叉配血单无签名为29%、输血知情同意书不合格为26%、临床用血审批不符合为48%、输血前评估及输血后疗效评价不具体为97%、输血执行无双签名为45%、输注起止及15分钟患者生命体征没有记录为84%、红细胞输注指征不合理为13%、FFP输注指征不合理为61%、输血后血袋保存不符合要求为19%。结论 输血病历的具体化评价有助于改善临床输血病历的质量,并完善临床输血管理的相关过程,保障临床用血的科学、合理。

关键词: 输血病历, 评价标准, 输血管理, 依法用血

Abstract: Objective Based on the evaluation,the relevant evaluation To find the weak link of clinical blood transfusion,medical record of clinical blood transfusion was evaluated. Method 148 cases of medical records about blood transfusion were chosen from 31 hospitals in which have carried out blood transfusion,the medical records of blood transfusion were evaluated by the criteria such as,orders of blood transfusion,inspection Results before blood transfusion,application of blood transfusion,informed consent of blood transfusion,progress notes of blood transfusion,records of blood transfusion progress,grasp of blood transfusion indications,the rate of component transfusion and the rate of red cell utilization. Result 71% of cases had no history of blood transfusion or pregnancy description; 3% of cases had the errors of blood transfusion type; 29% of cases had no signature on the cross matching blood list; 26% of cases had no doctor signature or date on the informedconsent of blood transfusion; 48% of cases didn't establish clinical blood examination and approval system or had unqualified applications; 97% of cases had defective evaluation content of blood transfusion; 3% of cases had no efficacy evaluation after transfusion or the transfusion evaluation was not specific; 45% of cases had no dual signature of transfusion execution; The patient's vital signs were not recorded at the beginning and the end of the 15 minutes of infusion in 84% of cases; 13% of cases had unreasonable indications of red blood cell transfusion. 61% of cases had unreasonable indications of FFP; the preservation of blood bags didn't meet the requirements after the blood transfusion in 19% of cases. Conclusion The specific evaluation of blood transfusion can help to improve the quality of clinical blood transfusion records,improve the management process of clinical blood transfusion,and ensure the scientific and rational use of clinical blood. At the same time,it can improve the management process of clinical transfusion,to find out the unqualified items of blood transfusion medical record,make continuous improvement,ensure scientific and rational use of blood for clinical use.

Key words: Records of blood transfusion, Evaluation criteria, Blood transfusion management, Blood use in accordance with the law

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