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 related to transfusion of fresh blood or blood components.

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

The Serious transfusion incident report 2017-18 and summary report 2017-18 are now available to download

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 be contacted for additional details if they are required.

National haemovigilance

The National Blood Authority (NBA) has developed the reporting and governance frameworks for a National voluntary haemovigilance program. This program uses data provided by each jurisdiction. STIR reports into the national haemovigilence program which 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

STIR Bulletins are produced to highlight cases of interest prior to publishing the annual STIR report. Read the STIR Bulletin 3 now available to download. This bulletin showcases the management of suspected anaphylaxis due to blood product transfusion. Information included in the bulletin:

  • Incidence and causes
  • Recognition and response
  • Investigation and reporting

The previous STIR bulletins

  1. Parvovirus case vignette: Discusses the transmission of parvovirus via a blood transfusion and the subsequent investigation to identify the source of the illness.
  2. The "untransfusable" patient: what do I do? Provided case scenarios of patients' who's blood groups have created challenges for the pathology service to provide appropriately crossmatched blood. 

Reducing risk in transfusion

STIR uses the information from investigations received to make recommendations for improved transfusion practice.

Some things that may help health services reduce risk associated with transfusion are:

  • TACO awareness campaign – Transfusion-associated circulatory overload (TACO) is the most common cause of death and major morbidity due to transfusion and is potentially avoidable. The aim of the 2017 campaign was to raise the awareness of TACO to clinical staff. Supporting material (swing tag, poster and evaluation) from this campaign are available for download.
  • Reducing harm in blood transfusion: investigating the human factors behind ‘wrong blood in tube’ (WBIT) events in the emergency department undertaken by the Transfusion Outcomes Research Collaborative and reported to the Victorian Managed Insurance Authority, July 2010. It comprises a descriptive study of factors impacting specimen labelling and patient identification, both of which are major causes of WBIT events. 

Reducing harm in blood transfusion: investigating the human factors behind ‘wrong blood in tube’ (WBIT) events in the emergency department (PDF) 

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