In order to implement the Ministry of Health's Measures for the Administration of Clinical Blood Use in Medical Institutions and the Provincial Health Planning Commission's Notice on Further Strengthening Blood Management. Promote the scientific and rational use of blood in clinic, put an end to blood waste and abuse, and ensure the quality and safety of blood used in clinic. According to the actual situation of our hospital and referring to the technical specification of clinical blood transfusion of the Ministry of Health. These measures are formulated and all departments are expected to comply with them.
I. Organization and responsibilities
In order to further strengthen the management of clinical blood use in hospitals, promote the scientific and rational use of blood, protect blood resources, and ensure the safety and medical quality of clinical blood use, a clinical blood use management committee was established, with the following members:
Chairman: Vice President of Business
Vice Chairman: Vice Chairman, Minister of Medical Department, Director of Blood Transfusion Department.
Member: heads of relevant departments.
Committee members are responsible for the daily management of clinical rational use of blood, and their main responsibilities are:
First, implement the relevant national laws, regulations and departmental rules on the management of clinical blood, formulate management systems such as blood reservation, receipt, warehousing, custody, distribution, inventory warning and clinical rational use of blood, and improve management systems, mechanisms and specific processes such as application, review, monitoring, analysis, evaluation and improvement of clinical blood.
Second, the establishment of clinical blood transfusion quality management system, formulate hospital blood transfusion management system, job responsibilities, and supervise the implementation; Actively advocate the establishment of a scientific, reasonable, effective and safe blood transfusion concept, and provide technical advice and practical guidance. The review of clinical blood use includes but is not limited to blood use application, informed consent of blood transfusion treatment, indication judgment, blood matching, blood collection and supply, clinical blood transfusion, observation during blood transfusion and post-transfusion management. And record the whole process to ensure the traceability of information, improve the system of clinical rational blood use evaluation and application of results, as well as the monitoring and disposal process of transfusion adverse reactions.
Three, monitoring the safety, effectiveness and reliability of blood, blood products and blood substitutes, and evaluating the quality of blood transfusion cases.
Four, organize the investigation of serious adverse reactions and errors related to blood transfusion, and put forward measures and programs to prevent or reduce and eliminate them.
Five, supervise and inspect the daily business work of blood transfusion department, and coordinate the work of blood transfusion department and clinical department.
Six, formulate and implement the education and training plan of blood transfusion management, carry out the education and training of clinical rational use of blood, and promote the standardized popularization and application of new technologies and methods of blood transfusion.
Seven, organize clinical blood transfusion research work, improve the overall scientific research level of blood transfusion, encourage and promote the promotion and exploratory research of new technologies for clinical blood use.
Eight, regularly hold hospital blood transfusion management meeting, report the dynamic of blood transfusion management, formulate rectification plan according to the existing problems, and supervise the implementation.
Nine, submit the annual clinical blood transfusion work report to the hospital, and put forward reasonable suggestions.
Second, the management of blood for clinical use
In order to make scientific and rational use of blood resources and ensure the safety and medical quality of clinical blood use, according to the provisions of the Measures for the Administration of Clinical Blood Use in Medical Institutions of the Ministry of Health, the relevant requirements for clinical blood use in our hospital are hereby notified as follows:
Blood bank management
The blood bank shall establish corresponding accounts for receiving, warehousing, storage and distribution, and the contents shall be registered completely. After receiving the blood, the blood bank shall check the label of the blood bag. Blood that meets the relevant national standards and requirements shall be put into storage, properly registered, and orderly stored in special storage facilities according to different varieties, blood types and blood collection dates (or expiration dates). The main contents of blood bag label inspection:
(1) the name of the blood;
(2) Blood donation code or barcode, blood type;
(3) blood variety;
(4) Date and time of blood collection or date and time of preparation;
(5) Validity period and time;
(6) Storage conditions. It is forbidden to put unqualified blood bags into storage.
The blood storage facilities shall ensure the effective operation, and the storage temperature of whole blood cells shall be controlled at 2-6oC and the storage temperature of platelets at 20-24oC. The blood storage personnel shall make a 24-hour monitoring record of the blood storage temperature, and record it four times a day and sign it.
The blood storage refrigerator has disinfection records and complete culture records.
Check carefully when blood is distributed, designate medical personnel to take blood, and both parties shall sign it, which must be complete, neat and identifiable.
Do a good job in early warning of blood in stock, report the stock situation to the medical department in time when the blood is tight, and make an emergency blood use plan.
Management of clinical blood use
(1) medical staff should conscientiously implement the technical specifications of clinical blood transfusion, strictly grasp the clinical blood transfusion indications, comprehensively evaluate the blood transfusion indications according to the patient's condition and laboratory test indicators, and formulate a blood transfusion treatment plan.
(2) Before blood transfusion, doctors should explain the purpose, mode and risk of blood transfusion to patients or their close relatives, and sign the informed consent form of clinical blood transfusion.
(3) If emergency blood transfusion is needed to rescue dying patients, and the opinions of patients or their close relatives cannot be obtained, blood transfusion treatment can be implemented immediately after the approval of the person in charge of the hospital or the authorized person in charge.
(4) The hospital implements hierarchical management for clinical blood use applications:
If the same patient applies for blood matching less than 800 ml a day, it shall be applied by a doctor with the qualification of attending physician or above, and the blood matching can be carried out only after being approved and signed by a superior doctor.
The same patient applies for blood matching within the range of 800 ml to 1600 ml a day, and the application is made by a doctor with professional and technical post qualifications above the attending physician, and the blood matching can only be carried out after being examined and signed by the superior doctor and approved by the department director.
If the same patient applies for matching blood to reach or exceed 1600 ml a day, the application shall be made by a doctor with professional and technical post qualifications above the attending physician, and the director of the department shall report to the medical department for approval before matching blood.
The above provisions do not apply to emergency blood use. If it is blood for emergency use, it should be indicated when applying.
Third, supervision and management.
1. All departments should strengthen the training of medical staff on the knowledge of clinical blood use and voluntary blood donation.
2. Establish the evaluation and publicity system for clinical blood use by departments and doctors. Clinical blood is included in the work assessment indicators of departments and medical staff.
3. Incorporate the training of clinical blood-related knowledge into the content of continuing education. New medical staff must receive pre-job training and assessment of clinical blood-related knowledge, and they can engage in corresponding diagnosis and treatment activities only after passing the examination.