Department of Health

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 for a health service code if this is your first report.

Submit a report using the e-formExternal Link

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 AuthorityExternal Link 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

STIR reports and summaries








Reviewed 05 February 2024


Contact us

Blood Matters Program Australian Red Cross Lifeblood

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