中国输血杂志2023，Vol.36Issue(11)：1045-1049,5.DOI:10.13303/j.cjbt.issn.1004-549x.2023.11.018
输血不良事件管理系统构建及应用
Blood transfusion adverse event management system:construction and application
摘要
Abstract
Objective To establish a blood transfusion adverse event management system and apply it to adverse events management,so as to enhance the ability to identify and process reports as well as prevent adverse events.Methods Ac-cording to the errors during the whole process of blood transfusion,the management information system of blood transfusion adverse events was established,and the data of adverse transfusion reactions and adverse transfusion events from 2020 to 2022 were collected according to the system requirements.The system monitoring data and statistical analysis were used to analyze the causes of errors in each link of blood transfusion,sort the incidence of each department,focus on supervising the departments with high frequency of adverse events,and propose effective rectification.Results The management system counted 51 cases of adverse reactions.The incidence of adverse reactions of plasma(43.1%,22/51)was higher than that of red blood cells(39.2%,20/51),and the number of allergic reactions was slightly higher than that of febrile non-hemolytic transfusion reaction.Among the 628 cases of adverse transfusion events,blood transport,inbound and storage(TS-A)errors accounted for the highest proportion of 46.2%(290/628),20.9%(131/628)in post-transfusion disposal and evaluation(TS-G)and 15.8%(99/628)in pre-transfusion evaluation and transfusion application(TS-B).TS-A12 accounted for63.8%(185/290)in TS-A errors,which was mainly due to plasma leakage caused by extrusion during transport and the expira-tion of red blood cells caused by insufficient blood inventory management.TS-B errors mainly focus on the failure to fully assess the bleeding tendency of patients before surgical system surgery,resulting in no or insufficient preoperative blood prepa-ration.Most of the TS-G errors were unqualified medical record.Conclusion Blood transfusion adverse event management system can help to identify and prevent the occurrence or recur-rence of adverse events,formulate targeted rectification and preventive measures,and improve the haemovigilance ability.关键词
输血不良事件管理系统/血液安全监测/不良事件/输血不良反应Key words
blood transfusion adverse event management system/haemovigilance/adverse events/adverse transfusion reaction分类
医药卫生引用本文复制引用
吴学敏,李小飞..输血不良事件管理系统构建及应用[J].中国输血杂志,2023,36(11):1045-1049,5.基金项目
首都卫生发展科研专项(2121-1G-2021) （2121-1G-2021）
