摘要
目的分析血浆输注量不足不良事件的根本原因,探讨改进措施,优化输血流程,避免输血量不足不良事件发生。方法联合运用医疗失效模式与效应分析和根本原因分析法分析输血量不足事件原因,针对性提出改进措施并评估实施后效果。结果改进后,医院血浆输注量不足不良事件发生率明显下降;影响输血安全管理的风险优先数值由70分下降到8分,输血后血浆输注指征指标凝血功能检测比例由2012年的44.61%(1309/2934)提高到2019年80.55%(2187/2715);输血浆患者人均每次血浆用量由2012年300 mL提高到528 mL,2019年血浆输注患者输注前后PT和APTT值较2012年有明显改善。同时,住院患者整体血浆输注比例由3.16%(2934/92838)降低到2.12%(2715/128352)。结论联合运用医疗失效模式与效应分析和根本原因分析法进行临床用血质量与安全的风险管理,可以提高医院输血安全管理风险意识,优化血浆输注病例数与输注量的结构,对于保障输血安全合理有效、改善输血患者预后,起到非常重要的作用。
Objective To analyze the root causes of adverse events to insufficient plasma transfusion,so as to explore improvement measures,optimize the transfusion strategy and avoid such adverse events.Methods The root causes of insufficient plasma transfusion were analyzed by health care failure mode and effect analysis,the targeted improvement measures were formulated and the effect was evaluated.Results After the improvement,the incidence of adverse events to insufficient plasma transfusion decreased significantly.The risk priority value affecting the safety of blood transfusion decreased from 70 to 8,and the proportion of coagulation function test after blood transfusion increased from 44.61%(1309/2934)in 2012 to 80.55%(2187/2715)in 2019,and plasma transfusion volume per capital increased from 300 mL to 528 mL.PT and APTT values after plasma transfusion in 2019 significantly increased compared with those in 2012.Meanwhile,the proportion of plasma transfusion in hospitalized patients decreased from 3.16%(2934/92838)to 2.12%(2715/128352).Conclusion Risk management of quality and safety of blood transfusion by combing healthcare failure mode,effect analysis and root cause analysis(RCA)can improve the risk awareness of clinical blood transfusion,optimize the proportion of plasma transfusion,and is essential to ensure the safety and effectiveness of blood transfusion and improve the prognosis of transfused patients.
作者
吕莉
阙文君
李鑫
詹廷西
李青
秦攀
涂欢
余泽波
胡雪
LV Li;QUE Wenjun;LI Xih;ZHAN Tingxi;LI Qing;QIN Pan;TU Huan;YU Zebo;HU Xue(Department of Blood Transfusion,the First Affiliated Hospital of Chongqing Medical University,Chongqing 400016,China)
出处
《中国输血杂志》
CAS
2021年第9期978-982,共5页
Chinese Journal of Blood Transfusion
关键词
血浆输注量不足
不良事件
医疗失效模式与效应分析
根本原因分析
insufficient plasma transfusion
adverse events
healthcare failure mode and effect analysis
root cause analysis
