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目的:分析临床输血病历中存在的问题,探讨通过加强对输血病历的管理,促进临床输血的规范化,提高临床输血的安全性,防范输血所致医疗纠纷的发生。方法:以《临床输血技术规范》、《医疗机构临床用血管理办法》为主要依据,每周随机抽查内、外科运行病历各6~10份,对输血病历中的输血相关文书、输血医嘱、输血适应证、护理输血医嘱执行情况、输血不良反应等进行检查,并现场反馈,每个月将检查结果进行通报,提出整改意见。结果:2012-03-2013-02共随机抽查住院患者输血病历为458份,外科265份(57.86%),内科193份(42.14%);其中,存在缺陷病历159份(32.78%),外科123份(77.36%),明显高于内科(36份,22.64%);以患者输血知情同意书和输血病程记录存在缺陷最为常见。结论:部分临床医生对输血病历质量的重要性认识不足,应通过对输血病历的标准化和规范化,加强对临床输血病历质量的检查、分析和改进,增强医护人员对临床输血风险的认识,提高临床输血的安全、合理性,主动防范输血医疗纠纷发生。
OBJECTIVE: To analyze the existing problems in clinical transfusion records, and to explore ways to improve the safety of clinical transfusion and prevent medical disputes caused by blood transfusion by strengthening the management of transfusion records, promoting the standardization of clinical transfusion. Methods: Based on “clinical blood transfusion technical specifications” and “clinical blood management methods of medical institutions”, 6 to 10 copies of internal and external medical records were randomly selected each week. Blood transfusion related medical transcripts, transfusion doctor’s advice, Blood transfusion indications, the implementation of nursing transfusion doctor’s advice, adverse reactions such as blood transfusion and inspection, and on-site feedback, the inspection results will be reported every month, put forward suggestions for rectification. Results: 2012-03-2013-02 A total of 458 hospitalized transfusion records were randomly selected, 265 (57.86%) were surgical and 193 (42.14%) were medical records, of which 159 were defective (32.78%) and 123 (77.36%), which was significantly higher than that of internal medicine (36 and 22.64%). It was most common to have the patient’s blood transfusion informed consent and records of blood transfusion course defects. Conclusion: Some clinicians do not know enough about the importance of blood transfusion records. The standardization and standardization of blood transfusion records should be strengthened. The examination, analysis and improvement of clinical transfusion records should be strengthened so as to enhance medical staff awareness of clinical transfusion risks and improve clinical Blood transfusion safety, reasonable, take the initiative to prevent blood transfusion medical disputes.