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临床输血病历质量考核评价体系优化提升

蒋钱 尹明伟 陈学军 徐军 金小波

中国输血杂志2023,Vol.36Issue(11):1035-1039,5.
中国输血杂志2023,Vol.36Issue(11):1035-1039,5.DOI:10.13303/j.cjbt.issn.1004-549x.2023.11.016

临床输血病历质量考核评价体系优化提升

Optimization of quality assessment system of clinical blood transfusion records

蒋钱 1尹明伟 1陈学军 1徐军 1金小波1

作者信息

  • 1. 浙江大学医学院附属儿童医院 输血科 国家儿童健康临床研究中心,浙江 杭州 310052
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摘要

Abstract

Objective To determine the value of quality assessment system in supervising standard clinical blood use and improving the quality of clinical blood transfusion medical records.Methods The clinical blood transfusion records of Children's Hospital,Zhejiang University School of Medical every quarter from January 2019 to December 2022 were selected and extracted for evaluation by 5% to 10% for the current season.These blood transfusion medical records were scored and graded A(≥90 points)/B(80-89 points)/C(<80 points)according to the Evaluation Table of Clinical Science Rational Use of Blood in Children's Hospital of Zhejiang University,and the annual A rate was statistically analyzed.After summarizing the deduction points,a rectification plan was submitted to the medical department and publicized on the hospital network.Re-sults A total of 1 975 blood transfusion medical records were analyzed from January 2019 to December 2022,including 343 in 2019(17.37%),517 in 2020(26.18%),556 in 2021(28.15%)and 559 in 2022(28.30%),with Grade A rates at 67.06%,92.07%,93.17% and 91.06%,respectively.According to Pearson Chi-square test,the Grade A rates of blood trans-fusion records in 2020,2021 and 2022 were significantly higher than those in 2019(P<0.000 1).In the assessment,the main reasons for deduction of points were missed pre-transfusion immunization tests and missed blood transfusion course records.From 2019 to 2022,the missed rates of pre-transfusion immunization tests were 22.68%,6.47%,1.26% and 2.49%,and the missed rates of blood transfusion course records were 32.21%,10.59%,5.57% and 6.61%,respectively.Conclusion The reg-ular and reasonable assessment and publicity system of blood transfusion medical records is conducive to improving the quality of blood transfusion medical records,promoting rational blood use and ensuring the safety of blood use for children.

关键词

临床输血/考核评价体系/病历质量管理/输血安全

Key words

clinical blood transfusion/assessment system/medical record quality management/blood transfusion safety

分类

临床医学

引用本文复制引用

蒋钱,尹明伟,陈学军,徐军,金小波..临床输血病历质量考核评价体系优化提升[J].中国输血杂志,2023,36(11):1035-1039,5.

中国输血杂志

1004-549X

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