摘要
目的通过输血病历质量改进,完善输血病历书写规范与质控标准,促进临床合理、有效、安全输血。方法对2011年住院病案中输血相关记录,包括病案首页、输血医嘱、病程记录(含术中输血记录)、护理记录、输血记录单、输血知情同意书、输血前筛查、输血会诊及合理用血的各个环节进行系统检查、分析缺陷原因,制订质量改进计划,运用持续质量改进(CQI)方法指导2012年输血病历书写规范。结果上述输血相关记录缺陷发生率2012年较2011年明显减少,两者比较有统计学差异(P值<0.01),输血病历达标率从74.86%提高到92.26%,质量改进达到预期效果。结论采用持续质量改进方法,能有效提高输血病历书写质量,提高医护人员法律意识,规范医疗行为,保证医疗安全。
Objective Through quality improvement of the blood transfusion records, to complete the written standard and quality control standard of blood transfusion records, and to promote reasonable, effective, and safe blood transfusion in clinics. Methods Systematically checked all the concerned records of blood transfusion in the previous medical records in 2011, including front sheet of the record, doctor＇s advice about blood transfusion, records of the disease process （including blood transfusion record during operation process）, nursing records, blood transfusion record sheet, informed consent form of blood transfusion, screening before blood transfu- sion, blood transfusion consultation, and all the links of rational use of blood, analyzed the causes of the defect, formulated quality improvement plan, and guided the written standard of blood transfusion records in 2012 by utilizing the method of continuous quality improvement （CQI）. Results The incidence rate of the above mentioned record defect in 2012 was obviously reduced when compared that with 2011. Statistic difference occurred in the incidence rate of these two years （ P value 〈 0.01）, the rate of reaching the stan- dard about blood transfusion record was enhanced from 74.86 % to 92.26%, and the quality improvement reached to the expected ef- fect. Conclusion Continuously quality improvement method can effectively enhance the written quality of blood transfusion record, improve the legal consciousness of medical personnel, standardize the act of medical treatment, and ensure medical safety.
出处
《中国病案》
2013年第7期17-18,共2页
Chinese Medical Record
关键词
基层医院
输血病历
持续质量改进(CQI)
医疗安全
Grass-Root Hospital
Blood transfusion record
Continuous quality improvement （CQI）
Medical safety
