Serious Transfusion Incident Reporting€¦ · Serious Transfusion Incident Reporting: A key...
Transcript of Serious Transfusion Incident Reporting€¦ · Serious Transfusion Incident Reporting: A key...
Serious Transfusion Incident Reporting:A key activity of the Australian ‘Blood Matters’
blood management programme
Erica Wood on behalf of the STIR expert group:
Amanda Davis (Chair), Christine Akers, Helen Atkinson,
Gerald Bates, Peter Beard, Linley Bielby, Karen Botting, Philip Crispin,
Merrole Cole-Sinclair, James Daly, Cindy Flores, Bridget Glazebrook,
Clare Hennessy, Chris Hogan, Giles Kelsey, Ellen Maxwell, Scott McArdle,
Tina Noutsos, Dick Rogers, Adrienne Wynne, Anissa Yttrup
Comprehensive, state-wide
transfusion practice improvement program
Comprehensive, state-wide
transfusion practice improvement program
• STIR HV system established 2005-6 (pilot), expanded 2007
• Part of the Victorian Blood Matters (BM) best practice in blood
management program, established 2001
• Collaboration between
• Victorian Department of Health and Human Services (DHHS)
• Australian Red Cross Blood Service
• Participating public & private hospitals and laboratories
• BM Advisory Committee provides oversight, policy direction and
monitors progress
• Participation/representation in STIR from Tasmania, Australian
Capital Territory, Northern Territory
Aim and scope of STIR
• Aim: collate, analyse and report with recommendations for
improvements for better, safer transfusion practice
• Serious incidents (adverse reactions, process-related events,
including near misses)
• Fresh blood components (volunteer, family, autologous)
• Cell salvage and RhDIg since 2015
• TAD and DSTR added to national HV dataset by NBA – effective 1
July 2017
• Links with statewide Victorian sentinel event program
What and how to report?
Initial notification to STIR
Initial notification to STIR
Investigation forms tailored to type of event
Three levels of review:
Health service, STIR office, expert group
Diagnosis, severity, imputability all reviewed
Changed after review in ~5% of cases
(reported back to hospital)
Sharing the results and recommendations
• Feedback to individual health services (93 registered, 25-35 pa)
• Report validated, aggregate data and recommendations to inform
Victorian DHHS policy:
• Director, Cancer, Specialty Programs, Medical Research and International Health
• Sentinel Events Program
• Reports to other state/territory DoH
• Report validated, aggregate data to National Blood Authority for the
national HV dataset
• Report to professionals (presentations, publications)
• Annual report publicly available and widely distributed
Individual health service reports
• Six-monthly interim reports
• Annual reports with comparison to
peer group hospitals
• Sent to hospital contacts including
CEO/medical director
• Useful for range of local practice
improvement activities including
showing compliance with National
Safety and Quality Health Service
Standards (Australian Commission on
Safety and Quality in Health Care)
Aggregate reports to health services and
other interested parties
Comprehensive, state-wide
transfusion practice improvement program
Building capacity for specialist practitioners:
Graduate Certificate in Transfusion Practice
Online training program
17 current students
• 1 international
• 8 Aus interstate
• 3 medical scientists
142 students from 2004-17
Now Specialist Certificate in
Blood Management
Foundations (first semester)
and may continue to Grad
Cert in Transfusion Practice
Transfusion Nurse / Trainers / Safety Officers
22 staff across
15 Melbourne metro
health services
30 staff (10 EFT)
across 29 regional
health services
TSC in Australia
Population 2.6m
TP = 18
Population
0.246m
TP = 1
Population 1.69m
TP = 18
Population 4.74m
TP = 12
Population 7.54m
TP = 15
Population 5.86m
TP = 45Pop 0.551m
TP = 3
ACT
Pop 0.387m
TP = 1
Western
Australia
Northern
Territory
Queensland
South Australia
New South Wales
Victoria
Tasmania
• 113 hospital-based TPs
• 12 blood service-based TNs
• Established role in NZ also
• Strong links with other regional, national
practice improvement programs
Education and training for hospital and lab staff
Comprehensive, state-wide
transfusion practice improvement program
Conclusions
STIR is a robust regional HV system – integral to, and taking advantage of,
structures and relationships of the broader Blood Matters practice
improvement program
Strengths of the STIR/BM model:
• Provide validated HV data for national report
• Access to core BM project staff with expertise in transfusion practice improvement
• Efficiencies and opportunities in sharing resources and information across BM:
• Issues identified one area, tackle these across all areas (e.g. focused clinical audits,
provide tools and education/training)
• Links to policy and practice very broadly:
• Through BM, STIR represented on key national committees, including HV and
education/training groups
• Facilitates sharing of results and experience with policy-makers, management, education
providers and clinicians nationally and internationally
Acknowledgements
STIR team: Chris Akers (TN), Linley Bielby (program manager), Bridget
Glazebrook and Peter Beard (data managers) and all previous staff
STIR multidisciplinary expert group
Participating health services
Australian governments fund the Australian Red Cross Blood Service
to provide blood, blood products and services to the Australian community