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目的分析输血病案主要缺陷类型和缺陷表现,探讨提高输血病案质量的方法。方法分析2014年1月-2015年12月存在缺陷的442份输血病案,用帕累托图找出主要缺陷类型,针对主要缺陷类型找出缺陷表现。结果 10类缺陷类型中,病程记录、输血知情同意书、输血后评价、输血记录单、输血前相关检查5类缺陷为主要缺陷类型,累计构成比为79.81%;造成5类主要缺陷类型的表现有16个,其中输血前检查结果未填和缺少输血记录发生率较高,分别为12.64%和11.9%。结论应从加强医疗纠纷防范意识、开展输血病历书写专题培训、加强输血病案的环节质控、完善沟通反馈机制方面入手,促进输血病案质量持续改进。
Objective To analyze the main types of defects in transfusion cases and their defects, and to explore ways to improve the quality of transfusion cases. Methods 442 transfusion cases with defects from January 2014 to December 2015 were analyzed. Pareto charts were used to identify the major types of defects and the defects were identified according to the major types of defects. Results Among the 10 types of defect types, five types of defects were recorded as disease record, informed consent form of blood transfusion, post-transfusion evaluation, transfusion record sheet and related tests before transfusion. The total defect ratio was 79.81% There were 16 cases, of which the results of pretransfusion tests were not filled and the lack of transfusion records were higher, accounting for 12.64% and 11.9% respectively. Conclusion It is necessary to improve the quality of blood transfusion medical records by strengthening the awareness of prevention of medical disputes, carrying out special training on blood transfusion records writing, strengthening the quality control of blood transfusion cases and improving the communication and feedback mechanism.