本文選題：輸血 + 合理性　； 參考：《中國輸血雜志》2017年07期

【摘要】：目的調(diào)查醫(yī)院輸血病歷中存在的問題,分析不合理因素,不斷提高臨床輸血質(zhì)量。方法從本院2016年1月-2017年1月有輸血治療的病歷中,依據(jù)住院號利用隨機(jī)數(shù)字表法隨機(jī)抽取900份,調(diào)查每份輸血病歷中輸血有關(guān)記錄完整性,依據(jù)《臨床輸血技術(shù)規(guī)范》中"手術(shù)及創(chuàng)傷輸血指南"及"內(nèi)科輸血指南"結(jié)合患者體征,對常見成分血如紅細(xì)胞、血漿、及冷沉淀等輸注合理性進(jìn)行評價(jià)。結(jié)果抽取的病歷中手術(shù)科室583份,非手術(shù)科室317;手術(shù)科室與非手術(shù)科室臨床輸血病歷合理率存在差異,非手術(shù)科室的合理率高于手術(shù)科室(χ~2=7.723,P=0.021),非手術(shù)科室合理率為93.8%,而手術(shù)科室僅為88.0%;900份輸血病歷中4種血液成分輸注合理性差異具有統(tǒng)計(jì)學(xué)意義(χ~2=214.767,P0.001)。非手術(shù)科室紅細(xì)胞、血漿、冷沉淀合理率高于手術(shù)科室;900份病歷中有55份記錄不合格,主要是輸血后評估不全、未記錄輸血反應(yīng)。手術(shù)科室與非手術(shù)科室臨床輸血病歷相關(guān)記錄不合格率差異具有統(tǒng)計(jì)學(xué)意義(χ~2=4.613,P=0.032)。結(jié)論部分醫(yī)師掌握輸血適應(yīng)證欠佳,對于用血前評估及輸血后療效評價(jià)重視不足,存在輸血不合理,且以手術(shù)科室明顯,不重視輸血病歷書寫,醫(yī)院應(yīng)加強(qiáng)輸血管理不斷提高輸血的科學(xué)性、規(guī)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.
【作者單位】： 復(fù)旦大學(xué)附屬婦產(chǎn)科醫(yī)院輸血科;
【分類號】：R457.1

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