Key message
The Blood Matters Serious Transfusion Incidents Reporting system (STIR) 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
STIR Bulletin 10 Wrong blood in tube (WBIT) – what can we do to reduce errors?
This bulletin defines WBIT events, how they are recognised and their frequency. Two case scenarios describe how easily a WBIT can occur and provides a concluding summary of events that can improve safety
Reporting an incident
STIR guide
The STIR reporting 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.
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 haemovigilance 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 National Blood website.
Reducing risk in transfusion
STIR uses the information from investigations received to make recommendations for improved transfusion practice.
Transfusion Associated Circulatory Overload (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 2017 campaign aimed to raise awareness of TACO to clinical staff. Supporting material (swing tag, poster and evaluation) from this campaign are available for download:
STIR Bulletin
STIR Bulletins are produced to highlight cases of interest and potential practice changes that may affect patient care.
STIR Bulletins 2020 to 2023
-
A vignette discussing the transmission of parvovirus via a blood transfusion and the subsequent investigation to identify the source of the illness.
STIR Bulletin No. 1 - parvovirus case vignetteSTIR Bulletin No. 1 - parvovirus case vignette -
Case scenarios of patients whose blood groups have created challenges for the pathology service to provide appropriately crossmatched blood.
STIR Bulletin No. 2 - the untransfusable patient and what do I doSTIR Bulletin No. 2 - the untransfusable patient and what do I do -
Showcases the management of a suspected anaphylaxis due to blood product transfusion.
STIR Bulletin No. 3 - management of suspected anaphylaxis due to blood productsSTIR Bulletin No. 3 - management of suspected anaphylaxis due to blood products -
A discussion on transfusion errors that can be related to an EMR with examples from the field.
STIR Bulletin No. 4 - electronic medical records and transfusionSTIR Bulletin No. 4 - electronic medical records and transfusion -
A discussion of the implications for care of patients who experience a positive serological result related to passive (and significant) antibody transfer.
STIR Bulletin No. 5 - passive AB and IVIg 2020STIR Bulletin No. 5 - passive AB and IVIg 2020 -
A case study highlighting the risks and benefits associated with the use of O negative emergency red cell units.
STIR Bulletin No. 6 – issue of O RhD negative emergency red cell units - not without risk -
An overview of the current risk of bacterial infection related to blood component transfusion.
STIR Bulletin No. 7 - transfusion-transmitted bacterial infection and current mitigation strategies in AustraliaSTIR Bulletin No. 7 - transfusion-transmitted bacterial infection and current mitigation strategies in Australia -
Update to transfusion reaction STIR reporting definitions - an overview of the changes recently made to the reporting definitions for some STIR incident categories.
STIR Bulletin No. 8 - STIR changesSTIR Bulletin No. 8 - STIR changes -
Blood product checking - an overview of 3 incidents that could have been prevented by following correct pre-transfusion patient identification and product checking processes.
STIR Bulletin No. 9 - blood product checkingSTIR Bulletin No. 9 - blood product checking -
This bulletin defines WBIT events, how they are recognised and their frequency. Two case scenarios describe how easily a WBIT can occur and provides a concluding summary of events that can improve safety.
STIR Bulletin - no. 10 - Wrong blood in tubeSTIR Bulletin - no. 10 - Wrong blood in tube
STIR reports and summaries
2022-23
2021-22
2020-21
Reviewed 09 October 2024