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Blood Matters better safer transfusion program Essential elements of the Serious Transfusion Incident Reporting system (STIR) –Part 1 Lisa Stevenson Haemovigilance

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blood matters better safer transfusion program

Blood Mattersbetter safer transfusion program

Essential elements of the Serious

Transfusion Incident Reporting system (STIR) –Part 1

Lisa Stevenson

haemovigilance
Haemovigilance

“A system of surveillance and alarm, which encompasses all steps of the transfusion process, from blood collection to the follow-up of recipients”

Debeir J, Noel L, Aullen J, Frette C, Sari F, Mai MPV, Cosson A

Vox Sang 1999; 77: 77-81

introduction serious transfusion incident reporting system stir
Introduction Serious Transfusion Incident Reporting System (STIR)
  • Statewide reporting system in private and public hospitals; links with sentinel events program
  • Collects serious adverse events and near misses
    • Measure and monitor practice
    • Make recommendations for better, safer practice
  • FRESH blood products (red blood cells, fresh frozen plasma, platelets and cryoprecipitate)
  • From volunteer or family donors or autologous collections
shot the serious hazards of transfusion scheme
SHOT: The Serious Hazards of Transfusion Scheme
  • Launched in November 1996 UK
  • Voluntary, confidential, anonymous
  • Aims to capture data on major complications of transfusion
slide5

Total components issued 2.9 M

The Issues in TransfusionData from the SHOT report 2007.

slide6

Near miss events – SHOT 2005 n=1358

Sample errors

Request errors

products implicated
Products Implicated

*reported incidents involved more than one product unable to determine which product was involved

#Issue data is Victoria and Tasmania (Data ref ARCBS 2006-2007)

slide9

Actual adverse events are only the tip of the iceberg, and are far outnumbered by near-miss events!

Battles JB et al. Arch Pathol Lab Med 1998;122:231-238

near miss events stir
‘ Near Miss’ Events STIR
  • Definition

Any incident, that had the potential to cause harm, but didn’t due to timely intervention and or luck or chance. For example any incident which is recognised before transfusion took place but which, if undetected, could have resulted in the determination of wrong blood group, or issue, collection, or administration of an incorrect, inappropriate or unsuitable component.

wrong blood in tube wbit
Wrong blood in tube (WBIT)
  • Definition

A special category of near-miss event, where it is detected that the labelled blood sample has been collected from an incorrect patient, however the transfusion did not proceed

recognising an event
Recognising an event
  • The initial form (red/e form) has a summary of the main features and diagnostic tests.
  • Definitions are provided in the guide, pages 9 – 10;
    • Incorrect blood component transfused (IBCT)
    • Acute transfusion reaction: excludes acute reactions due to IBCT
    • Delayed transfusion reaction: occurring >24 hours post-trfn
    • Transfusion-Related Acute Lung Injury (TRALI)
    • Transfusion-Associated Graft-Versus-Host Disease

(TA-GVHD)

    • Post-transfusion purpura (PTP)
    • Transfusion-transmitted infections (bacterial, viral, parasitic)
    • Near misses
    • Wrong blood in tube – a special category of near miss
sentinel events
Sentinel Events
  • if there is an event that fits within the sentinel event program
    • ABO incompatibility
    • other-catastrophic event
  • continue to report it through the sentinel event program, where a Root Cause Analysis is conducted
  • STIR are notified of the sentinel event from the sentinel event program and are asked to review the healthservice recommendations
flowchart initial red form p 7
Flowchart (initial red form) p.7

Step ActionResponsibilityof:

Transfusion event reported

on general hospital-wide

incident form.

See NOTE 1.

Step 1

Clinical Staff

Quality/Risk Manager will

receive the report

Step 2

Quality/Risk Manager

BeST ‘Serious Transfusion

Incident Report’ completed

and forwarded to:

1. BeST Office (within 3 business days.) AND 2. Relevant hospital staff

and committees.

See NOTE 3 for sentinel events.

Hospital

Transfusion

Contact

Step 3

Step 4

Relevant hospital staff and committees. Also, ARCBSa notified if appropriate.

Blood Matters central office

AND

flowchart second report blue
Flowchart – Second report (blue)

Step ActionResponsibilityof:

Blood Matters forwards relevant

second layer of form (within one week)

(for more detailed data).

Step 5

BeST

Completion of second layer form

conducted/arranged by hospital

transfusion contact and forwarded to Blood Matters (within four weeks).

RCAb arranged if appropriate.

Quality/Risk

Manager

Step 6

Incident data entered

by Blood Matters

into database.

BeST

Step 7

Data verified and collated by expert

STIR group and reported back to hospitals

on trends.

BeST

Step 8

organisational readiness checklist
Organisational readiness checklist
  • To be completed by the health service
  • The purpose is to ensure that systems are in place prior to commencement of the incident reporting scheme
  • Is included in the guide
organisational readiness checklist17
Organisational readiness checklist
  • Includes:
    • senior management commitment
    • a hospital-wide incident reporting policy (that includes, transfusion incidents)
    • operational management aspects need to be in place (eg a transfusion committee or equivalent with clear reporting lines, clarity on roles and responsibilities)
    • Serious transfusion incident response (policy and procedures enable staff to identify an incident and know the reporting mechanism)
notification form
Notification Form

both an e form and a paper based form are available via the Blood Matters website to notify of a serious transfusion incident to STIR

slide19

STIR: e form www.health.vic.gov.au/bloodmatters

hospital code: aligned with the Victorian sentinel event program

with nature of incident may enter one or more categories but must select suspected or confirmed for each category.

reports can be entered by any clinician or manager, Quality department should be made aware of a report entered into STIR.

slide21

Completing the Second form

  • This form will assist with your investigation of the adverse event at this stage this is a paper based system but with work in progress for an electronic form.
  • Timelines for this form is four weeks from date of receiving.
where to get help
Where to get help
  • Contact the Blood Matters-better safer transfusion program
      • Lisa.Stevenson@dhs.vic.gov.au 03 9096 0476
      • Karen.Botting@dhs.vic.gov.au 03 9096 9037
      • Stir@dhs.vic.gov.au
  • STIR guide – available

on the website

slide24

Thankyou

Acknowledgments and thanks to:

STIR expert group

Blood Matters-better safer transfusion program

Department of Human Services and ARCBS

and the reporting hospitals of Victoria and Tasmania.