Key message

  • The Blood Matters Serious Transfusion Incidents Reporting system (STIR) is for reporting serious adverse transfusion events.

The Blood Matters Serious Transfusion Incident Reporting (STIR) system is a central reporting system for serious adverse events with transfusion of fresh blood or blood components.

For more information on categories of reportable events see the STIR guide.

Reporting an incident

Contact Blood Matters for a hospital code if this is your first report.

Complete the Serious transfusion incident reporting e-form and submit.

Unique patient identification details are not requested, with the exception of age and gender. Confidentiality of data is fundamental to the success of this scheme.

Investigation form

This form is generated by Blood Matters on receipt of the notification and will be sent to the email address listed in the notification form. You may also be contacted to obtain additional details if they are required.

National haemovigilance

The National Blood Authority (NBA) has developed the reporting and governance frameworks for a voluntary haemovigilance program for Australia.

This program reports on serious transfusion-related adverse events occurring in public and private hospitals.

Copies of their reports can be viewed through the NBA website.

STIR Bulletin

The latest STIR Bulletin is available for download. The bulletin is produced ad hoc to highlight cases of interest prior to publishing the formal STIR report.

TACO awareness campaign - 2017

Transfusion-associated circulatory overload (TACO) is the most common cause of death and major morbidity due to transfusion and is potentially avoidable. The 2016 Annual Serious Hazards of Transfusion (SHOT) report found TACO contributed to 14 deaths and 18 cases of major morbidity in the reporting period. The NBA Australian Haemovigilance Report (2016) has expressed concern that TACO events in Australia may be under-reported. 

The aim of the campaign was to raise the awareness of TACO to clinical staff. Swing tags and posters identifying at-risk patients, how to prevent, what to monitor, and how to treat were provided by Blood Matters to attach to units of red cells issued to patients from the laboratory/blood bank.

Supporting material (swing tag, poster and evaluation) from this campaign are available for download.

Reducing harm in blood transfusion

Reducing harm in blood transfusion: investigating the human factors behind ‘wrong blood in tube’ (WBIT) events in the emergency department outlines a descriptive study of factors impacting the ability to follow best practice in specimen labelling and patient identification, both of which are major causes of WBIT events.

The study was undertaken by the Transfusion Outcomes Research Collaborative, and the report prepared for the Victorian Managed Insurance Authority, July 2010.

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