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.
The Serious Transfusion Incident Reporting annual report 2020-21 and summary report 2020-21 are now available to download.
Summary report 2020-21
Annual report 2020-21
Reporting an incident
The STIR guide provides information on when and how to report an event.
Contact Blood Matters 03 9694 0102 or firstname.lastname@example.org 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.
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.
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 NBA .
STIR Bulletins are produced to highlight cases of interest and potential practice changes that may affect patient care.
The available bulletins:
- A vignette discussing the transmission of parvovirus via a blood transfusion and the subsequent investigation to identify the source of the illness.
- Case scenarios of patients whose blood groups have created challenges for the pathology service to provide appropriately crossmatched blood.
- Showcases the management of a suspected anaphylaxis due to blood product transfusion.
- A discussion on transfusion errors that can be related to an EMR with examples from the field.
- A discussion of the implications for care of patients who experience a positive serological result related to passive (and significant) antibody transfer.
- A case study highlighting the risks and benefits associated with the use of O negative emergency red cell units.
- An overview of the current risk of bacterial infection related to blood component transfusion.
- Update to transfusion reaction STIR reporting definitions - an overview of the changes recently made to the reporting definitions for some STIR incident categories.
- Blood product checking - an overview of 3 incidents that could have been prevented by following correct pre-transfusion patient identification and product checking processes.
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 awareness of TACO to clinical staff. Supporting material (swing tag, poster and evaluation) from this campaign are available for download.
Reports and summaries
Reviewed 19 May 2023