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目的调查分析输血病案书写情况,以便更好落实、改进医院输血病案质量管理措施,提高临床输血质量;保障输血安全。方法回顾性调查2013年-2015年91份临床输血病案,对调查结果进行分析。结果 2015年与2013年相比,病案首页不合格率下降幅度最大85.7%、知情同意书、输血前检查、输血病程记录、输血护理记录、输血记录单、出院记录不合格率降幅分别是-7.4%、14.1%、-1.4%、20.3%、37.9%、25%。结论输血病案书写质量管理有一定效果,但在输血病案书写规范性、完整性方面仍存在很大问题,主管部门应加强培训和督导,以持续改进输血病案书写质量,确保输血安全,减少输血医疗纠纷的发生。
Objective To investigate and analyze the writing of transfusion cases in order to better implement and improve the quality management measures of transfusion cases in hospitals so as to improve the quality of clinical transfusion and ensure the safety of blood transfusion. Methods A retrospective survey of 91 clinical transfusion cases from 2013 to 2015 was conducted to analyze the survey results. Results Compared with 2013, the unqualified rate of the first page of medical records dropped by 85.7% in most cases. Informed consent, pre-transfusion tests, transfusion records, transfusion records, transfusion records and discharge records were all decreased by -7.4 %, 14.1%, - 1.4%, 20.3%, 37.9%, 25%. Conclusion The quality management of blood transfusion cases has some effects. However, there are still some problems in the standardization and completeness of blood transfusion cases. The competent departments should strengthen training and supervision in order to continuously improve the writing quality of transfusion cases, ensure the safety of blood transfusion and reduce the number of transfusion medicine Occurrence of disputes.