临床输血病历质量的规范化管理和持续改进

发布时间：2018-04-29 18:18

本文选题：输血病历 + 规范管理　；参考：《中国输血杂志》2016年10期

【摘要】：目的规范临床输血病历管理,提高临床输血病历管理质量,确保输血安全。方法依据国家有关法律法规,制定我院临床输血病历质量控制计划,采用随机抽查与重点检查相结合方式对546份临床输血病历的19项临床输血病历质量控制项目进行检查、统计和分析,实施PDCA持续改进方案。结果 2015年临床输血申请单和知情同意书填写完整性、临床输血病历病程记录完整性和术中出血量记录等项目合格率比2014年都有显著提高(P0.05);其它临床输血病历质量检查项目合格率也表现出不同程度提高;输血后疗效评价合格率有待进一步改进。结论采取临床输血病历质量检查等综合措施,通过PDCA持续改进,有利于规范临床输血病历管理,提高临床输血全流程管理质量。
[Abstract]:Objective to standardize the management of clinical transfusion records, improve the quality of clinical transfusion records management and ensure the safety of blood transfusion. Methods according to the relevant national laws and regulations, the quality control plan of clinical blood transfusion records in our hospital was formulated. The quality control items of 546 clinical transfusion records were examined by random sampling and key examination. Statistics and analysis, implement PDCA continuous improvement program. Results the clinical blood transfusion application form and informed consent form were completed in 2015. Compared with 2014, the qualified rate of clinical blood transfusion records, such as the integrity of history records and intraoperative blood loss, was significantly improved (P 0.05), and the qualified rates of other items of quality examination of clinical transfusion records were also improved to some extent. The qualified rate of post-transfusion efficacy evaluation needs further improvement. Conclusion adopting comprehensive measures such as quality examination of clinical transfusion records and continuous improvement of PDCA can help to standardize the management of clinical transfusion records and improve the quality of the whole flow management of clinical blood transfusion.
【作者单位】：海南省农垦总医院输血科;
【分类号】：R457.1;R197.323

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