Key message

  • The Blood Matters Serious Transfusion Incidents Reporting (STIR) system aims to provide information to health services to improve recognition and management of transfusion risks by providing:

- a central reporting system for Victorian health services to report serious adverse transfusion events, which are assessed by an expert group.

- de-identified data to health services about their reported incidents

- an annual report on de-identified statewide reported serious events.

 

What's new

The Serious transfusion incident report 2018-19 (PDF/Word) and Summary report 2018-19 are now available to download

Reporting an incident  

STIR guide

The STIR guide provides information on when and how to report an event. 

Contact Blood Matters (03 9694 0102) or stir@redcrossblood.org.au for a health service code if this is your first report. 

Submit a report using the e form

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 health services.

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

STIR Bulletin

STIR Bulletins are produced to highlight cases of interest and potential practice changes that may affect patient care.

The available bulletins

  1. Parvovirus – A vignette discussing 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?  - Case scenarios of patients' who's blood groups have created challenges for the pathology service to provide appropriately crossmatched blood. 
  3. Allergic reactions – showcases the management of a suspected anaphylaxis due to blood product transfusion.
  4. Electronic medical records and transfusion -  A discussion on transfusion errors that can be related to an EMR with examples from the field.
  5. Passive transfer of antibodies in patients receiving intravenous immunoglobulin (IVIg) – A discussion of the implications for care of patients who experience a positive serological result related to passive (and significant) antibody transfer.

Reducing risk in transfusion

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

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.

Contact details