Blood Matters better safer transfusion program Essential elements of the Serious Transfusion Incident Reporting system (STIR) –Part 1 Lisa Stevenson Haemovigilance
Essential elements of the Serious
Transfusion Incident Reporting system (STIR) –Part 1
“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
The Issues in TransfusionData from the SHOT report 2007.
*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)
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
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.
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
Transfusion event reported
on general hospital-wide
See NOTE 1.
Quality/Risk Manager will
receive the report
BeST ‘Serious Transfusion
Incident Report’ completed
and forwarded to:
1. BeST Office (within 3 business days.) AND 2. Relevant hospital staff
See NOTE 3 for sentinel events.
Relevant hospital staff and committees. Also, ARCBSa notified if appropriate.
Blood Matters central office
Blood Matters forwards relevant
second layer of form (within one week)
(for more detailed data).
Completion of second layer form
conducted/arranged by hospital
transfusion contact and forwarded to Blood Matters (within four weeks).
RCAb arranged if appropriate.
Incident data entered
by Blood Matters
Data verified and collated by expert
STIR group and reported back to hospitals
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
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.
on the website
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.