手术输血病案质量缺陷分析与对策

目的分析手术输血病案质量存在的问题，加强输血病案规范化管理，持续改进输血病案质量。方法对某三级综合医院2011年三、四季度手术输血病案进行终末质控检查，并将存在的质量缺陷进行统计。结果质控手术输血病案内容包括：手术护理记录、麻醉记录、手术记录、术后首次病程记录。质控检查三季度1177份，四项内容较完整记录输血晴况的693份，占质控总数的58．87％，缺陷率最高的是术后首次病程记录355份，占质控总数的30．16％；四季度1135份，四项内容较完整记录输血情况的822份，占质控总数的72．42％，缺陷率最高的仍是术后首次病程记录214份，占质控总数的18．85％。结论医疗机构在终末质量控制的基础上增加环节质量管理，加强医务人员对《临床输血技术规范》、《医疗机构临床用血管理办法（试行）》等法律法规的学习，加强输血病案质量管理，规范输血治疗记录，持续提高输血病案的内涵质量，确保输血治疗的安全性，避免医疗纠纷。

Quality Defect Analysis of Operation Blood Transfusion Medical Records and Its Countermeasures

Objective To analyze quality problems of operation blood transfusion medical records, strengthen the standardized management of blood transfusion medical records, improve the quality of blood transfusion records. Methods The terminal quality control inspection and statistics of the third, fourth quarters operation blood transfusion records were taken in a tertiary general hospital in 2011. Results The quality control operation blood transfusion records include operation nursing record, anesthesia records, operation records, the first postoperative records. Conclusion 1177 blood transfusion medical records were quality controlled in the third quarter. The four items of 693 blood transfusion medical records were complete, ac- counting for 58.87%. The highest defect rate is the first postoperative records, accounting for 30.16%. 1135 blood transfusion medical records were quality controlled in the fourth quarter. The four items of 822 blood transfusion medical records were complete, accounting for 72.42%. The highest defect rate is the first postoperative records, accounting for 18.85%. Conclusion Medical Institutions should increase the link quality management based on terminal quality control, strengthen laws and regulations study such as ＂clinical blood transfusion technical regulation＂ and ＂medical Institu- tions clinical blood use management method＂, strengthen quality management, regulate blood transfusion treatment records, improve the quality of blood transfusion records, ensure the safety of blood transfusion therapy, avoid medical disputes.