900份临床输血病历合理性调查分析

发布时间：2018-05-09 00:15

本文选题：输血 + 合理性　；参考：《中国输血杂志》2017年07期

【摘要】：目的调查医院输血病历中存在的问题,分析不合理因素,不断提高临床输血质量。方法从本院2016年1月-2017年1月有输血治疗的病历中,依据住院号利用随机数字表法随机抽取900份,调查每份输血病历中输血有关记录完整性,依据《临床输血技术规范》中"手术及创伤输血指南"及"内科输血指南"结合患者体征,对常见成分血如红细胞、血浆、及冷沉淀等输注合理性进行评价。结果抽取的病历中手术科室583份,非手术科室317;手术科室与非手术科室临床输血病历合理率存在差异,非手术科室的合理率高于手术科室(χ~2=7.723,P=0.021),非手术科室合理率为93.8%,而手术科室仅为88.0%;900份输血病历中4种血液成分输注合理性差异具有统计学意义(χ~2=214.767,P0.001)。非手术科室红细胞、血浆、冷沉淀合理率高于手术科室;900份病历中有55份记录不合格,主要是输血后评估不全、未记录输血反应。手术科室与非手术科室临床输血病历相关记录不合格率差异具有统计学意义(χ~2=4.613,P=0.032)。结论部分医师掌握输血适应证欠佳,对于用血前评估及输血后疗效评价重视不足,存在输血不合理,且以手术科室明显,不重视输血病历书写,医院应加强输血管理不断提高输血的科学性、规范性。
[Abstract]:Objective to investigate the problems existing in the medical records of blood transfusion in hospitals, analyze the unreasonable factors and improve the quality of clinical blood transfusion. Methods from January 2016 to January 2017, 900 medical records of blood transfusion in our hospital were randomly selected by random digit table according to the hospital hospitalization number, and the integrity of the records related to blood transfusion was investigated. According to the Technical Specification for Clinical Blood Transfusion, the guidelines for Transfusion of surgery and Trauma and the guidelines for Internal Transfusion combined with the signs of patients, the reasonableness of transfusion of common components such as red blood cell, plasma and cryoprecipitation were evaluated. Results 583 surgical departments and 317 non-operative departments were selected, and the reasonable rate of clinical blood transfusion was different between the surgical department and the non-operative department. The reasonable rate of non-operative department was higher than that of surgical department (蠂 ~ 2 / 2 ~ (7.723) P ~ (0.021), and the reasonable rate of non-operation department was 93.8, while that of operation department was only 88.0 ~ (th) and the reasonable rate of transfusion of four blood components in 900 blood transfusion cases was significantly different (蠂 ~ (2) ~ (2) ~ (2) ~ (14) 767P ~ (0.001). The rational rate of erythrocyte, plasma and cryoprecipitation in non-operative departments was higher than that in 900 medical records of surgical department. 55 records were not qualified, mainly because of incomplete post-transfusion evaluation and no blood transfusion reaction. There was significant difference in the unqualified rate of clinical blood transfusion records between the surgical department and the non-operative department (蠂 ~ 2 / 24.613 / P = 0.032). Conclusion the indications of blood transfusion are not well grasped by some doctors, the evaluation of blood before and after transfusion is not paid enough attention to, there is unreasonable blood transfusion, and the medical records of blood transfusion are obviously taken into account in the department of operation, and no attention is paid to the writing of blood transfusion cases. The hospital should strengthen the blood transfusion management to improve the science and standardization of blood transfusion.
【作者单位】：复旦大学附属妇产科医院输血科;
【分类号】：R457.1

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