医院输血病案质量缺陷及分析

目的加强输血病案规范管理,提高输血病案质量,防范临床用血医患纠纷。方法依据《北京市临床输血技术规范》、《北京市输血科（血库）评审细则》等制定的《输血病案缺陷检查表》,按表内项目对2011年1月1日-2011年12月31日的输血病案314份,分上下半年2次进行抽查。100分为满分;95-99分为一般缺陷;95分以下为严重缺陷,判为不合格病案。结果 2次抽查,其100分病案从上半年占总数的61.7%,提高到82%;缺陷病案从上半年占总数的38.3%,降低到18%,不合格病案从占总数15.1%降低到6.5%。结论输血病案质量的规范与否,直接影响病案内涵和医疗质量与安全,医院应当加强输血病案质量管理,确保医疗安全,避免医疗纠纷发生。

Defects and Countermeasures of Medical Records of Transfusion in a Hospital

Objective This paper aims at strengthening management of documents regulations of medical records of transfusion,improving quality of medical records of transfusion and preventing medical tangle risk of clinical usage of blood.Methods According to Defects Examination Table of Medical Records of Transfusion formulated by Beijing Technical Regulations of Clinical Transfusion,Evaluation Detailed Rules and Regulations of Department of Transfusion(blood bank) in Beijing,314 medical records of transfusion were randomly examined according to items in the table from Jan 1 2011 to Dec 31 2011,which were separated into first half year and second half year for spot check.It is took that 100 points as full score;95 to 99 points as the average defects;below 95 points as severe defects and unqualified medical records.Results In these two spot check,100 points of medical records from 61.7% raised to 82% accounting up in total number in first half year;defects medical records from 38.3% decreased to 18 accounting up in total number in first half year;unqualified medical records from 15.5% decreased to 6.5% accounting up in total number.Conclusions Whether the quality of transfusion medical records is standard may directly affect connotation and medical quality and safety of medical records.Hospital should enhance quality management of transfusion medical records,making sure the medical safety and avoiding the occurrence of medical tangle.