Serious Transfusion Incident Reporting:A key activity of the Australian ‘Blood Matters’

blood management programme

Erica Wood on behalf of the STIR expert group:

Amanda Davis (Chair), Christine Akers, Helen Atkinson,

Gerald Bates, Peter Beard, Linley Bielby, Karen Botting, Philip Crispin,

Merrole Cole-Sinclair, James Daly, Cindy Flores, Bridget Glazebrook,

Clare Hennessy, Chris Hogan, Giles Kelsey, Ellen Maxwell, Scott McArdle,

Tina Noutsos, Dick Rogers, Adrienne Wynne, Anissa Yttrup

Comprehensive, state-wide

transfusion practice improvement program

Comprehensive, state-wide

transfusion practice improvement program

• STIR HV system established 2005-6 (pilot), expanded 2007

• Part of the Victorian Blood Matters (BM) best practice in blood

management program, established 2001

• Collaboration between

• Victorian Department of Health and Human Services (DHHS)

• Australian Red Cross Blood Service

• Participating public & private hospitals and laboratories

• BM Advisory Committee provides oversight, policy direction and

monitors progress

• Participation/representation in STIR from Tasmania, Australian

Capital Territory, Northern Territory

Aim and scope of STIR

• Aim: collate, analyse and report with recommendations for

improvements for better, safer transfusion practice

• Serious incidents (adverse reactions, process-related events,

including near misses)

• Fresh blood components (volunteer, family, autologous)

• Cell salvage and RhDIg since 2015

• TAD and DSTR added to national HV dataset by NBA – effective 1

July 2017

• Links with statewide Victorian sentinel event program

What and how to report?

Initial notification to STIR

Initial notification to STIR

Investigation forms tailored to type of event

Three levels of review:

Health service, STIR office, expert group

Diagnosis, severity, imputability all reviewed

Changed after review in ~5% of cases

(reported back to hospital)

Sharing the results and recommendations

• Feedback to individual health services (93 registered, 25-35 pa)

• Report validated, aggregate data and recommendations to inform

Victorian DHHS policy:

• Director, Cancer, Specialty Programs, Medical Research and International Health

• Sentinel Events Program

• Reports to other state/territory DoH

• Report validated, aggregate data to National Blood Authority for the

national HV dataset

• Report to professionals (presentations, publications)

• Annual report publicly available and widely distributed

Individual health service reports

• Six-monthly interim reports

• Annual reports with comparison to

peer group hospitals

• Sent to hospital contacts including

CEO/medical director

• Useful for range of local practice

improvement activities including

showing compliance with National

Safety and Quality Health Service

Standards (Australian Commission on

Safety and Quality in Health Care)

Aggregate reports to health services and

other interested parties

Comprehensive, state-wide

transfusion practice improvement program

Building capacity for specialist practitioners:

Graduate Certificate in Transfusion Practice

Online training program

17 current students

• 1 international

• 8 Aus interstate

• 3 medical scientists

142 students from 2004-17

Now Specialist Certificate in

Blood Management

Foundations (first semester)

and may continue to Grad

Cert in Transfusion Practice

Transfusion Nurse / Trainers / Safety Officers

22 staff across

15 Melbourne metro

health services

30 staff (10 EFT)

across 29 regional

health services

TSC in Australia

Population 2.6m

TP = 18

Population

0.246m

TP = 1

Population 1.69m

TP = 18

Population 4.74m

TP = 12

Population 7.54m

TP = 15

Population 5.86m

TP = 45Pop 0.551m

TP = 3

ACT

Pop 0.387m

TP = 1

Western

Australia

Northern

Territory

Queensland

South Australia

New South Wales

Victoria

Tasmania

• 113 hospital-based TPs

• 12 blood service-based TNs

• Established role in NZ also

• Strong links with other regional, national

practice improvement programs

Education and training for hospital and lab staff

Comprehensive, state-wide

transfusion practice improvement program

Conclusions

STIR is a robust regional HV system – integral to, and taking advantage of,

structures and relationships of the broader Blood Matters practice

improvement program

Strengths of the STIR/BM model:

• Provide validated HV data for national report

• Access to core BM project staff with expertise in transfusion practice improvement

• Efficiencies and opportunities in sharing resources and information across BM:

• Issues identified one area, tackle these across all areas (e.g. focused clinical audits,

provide tools and education/training)

• Links to policy and practice very broadly:

• Through BM, STIR represented on key national committees, including HV and

education/training groups

• Facilitates sharing of results and experience with policy-makers, management, education

providers and clinicians nationally and internationally

Acknowledgements

STIR team: Chris Akers (TN), Linley Bielby (program manager), Bridget

Glazebrook and Peter Beard (data managers) and all previous staff

STIR multidisciplinary expert group

Participating health services

Australian governments fund the Australian Red Cross Blood Service

to provide blood, blood products and services to the Australian community