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目的:结合国家卫生部《三级综合医院评审标准(2011版)》实施细则有关输血管理与持续改进中对临床输血病历记录的要求,探讨临床输血申请单审核、临床输血病历规范化管理的必要性,以提高临床输血的质量,确保临床输血的安全有效。方法:针对本院2012年1月—2012年6月住院患者临床输血申请单2828份及抽查输血病历1450份中存在的主要问题进行分析。结果:在2828份输血申请单中有529份填写不合格,占总数的18.7%;抽查输血病历1023份,占输血病历的70.5%,不合格病例172份,占16.8%。结论:完善临床用血的组织管理,制定临床用血记录规章制度与流程,加强临床医护人员临床输血知识培训,规范临床输血病历记录,定期进行临床输血病历检查,保障临床用血安全有效的进行。
OBJECTIVE: To investigate the requirements of clinical transfusion records in blood transfusion management and continuous improvement in accordance with the implementation rules of the “General Hospital Accreditation Criteria (version 2011) of the Third-Level General Hospital” issued by the Ministry of Health to discuss the necessity of standardized management of clinical transfusion requests and the clinical management of transfusion records , In order to improve the quality of clinical transfusion and ensure the safety and effectiveness of clinical transfusion. Methods: To analyze the main problems existing in our hospital from January 2012 to June 2012, including 2828 clinical transfusion application forms for inpatients and 1450 blood transfusion records. Results: Among 2828 transfusion requests, 529 failed to fill in the questionnaire, accounting for 18.7% of the total; 1023 transfused patients were randomly sampled, accounting for 70.5% of the transfusions; 172 failed, accounting for 16.8%. Conclusion: To improve the management of blood for clinical use, formulate rules and procedures for clinical use of blood records, strengthen clinical transfusion knowledge training for clinical staff, standardize records of clinical transfusion records, regularly check clinical transfusion records, and ensure safe and effective clinical blood transfusion .