Blood Matters – Serious Transfusion Incident report 2017-18
(The following notification from Blood Matters may be of interest to members)
“The annual Serious Transfusion Incident Report for 2017-18 from Blood Matters is available on the Blood Matters website https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/speciality-diagnostics-therapeutics/blood-matters/serious-transfusion-incidents
This report contains information on reactions, incidents and near misses that occurred in health services from Victoria, Tasmania, Australian Capital Territory and Northern Territory between 1 July 2017 and 30 June 2018.
Reports are voluntary in nature and de-identified to protect patients, staff and health service confidentiality. Data, case studies and recommendations to improve practice are presented. Of note, in this report, are the outcomes of two root cause analysis that may provide insight into how these events occur and how the risks can be reduced. We thank the health services involved for providing this information.
All registered health services will also receive an individual summary of the reactions, incidents and near miss events they reported during the same period.
Participating in the STIR program assists health services to report haemovigilance data at both jurisdictional and national levels, with de-identified data from STIR reported to the National Haemovigilance Report.
If your health service is not participating in STIR and wishes to, or you have any questions regarding your individual report or the STIR annual report, please contact the Blood Matters secretariat on 03 9694 3523 or email: STIR@redcrossblood.org.au.”
NZ Blood Service
Australian Red Cross Lifeblood
- Health professionals
- VIC Dept Health – Blood Matters
- NSW CEC – Blood Watch
- SA Health – BloodSafe
- QLD Health – Queensland Blood Management Program
- WA Dept of Health – Patient Management Program
- National Blood Authority
- Australian Commission on Safety and Quality in Healthcare
- Australian Haemophilia Centre Directors’ Organisation
Colleges and Societies
- The Royal College of Pathologists of Australasia
- Australian Institute of Medical Scientists
- Australian College of Nursing
- Haematology Society Australia & NZ
- Australasian Society of Haemostasis and Thrombosis
- Australian Society of Medical Research (ASMR)
General transfusion medicine
- NHS Blood and Transplant (NHSBT)
- Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee (JPAC)
(Transfusion guidelines, best practice and clinical information)
- British Blood Transfusion Society
- Better Blood Transfusion (eLearning)
- SHOT (Serious Hazards of Transfusion)
- International Society of Blood Transfusion (ISBT)
- Transfusion Evidence Library
- Canadian Blood Services Transfusion Medicine
Patient Blood Management specific
- Society for the Advancement of Blood Management
- Network for Advancement of Transfusion Alternatives
- AABB Patient Blood Management
- International Foundation for Patient Blood Management
Australian Genomics Health Alliance
(This may be of interest to medical members as it is specifically targeting medical specialists and asking them about their practice with regard to requesting genomics testing).
The Australian Genomics Health Alliance which is an NH&MRC-funded study is gathering perspectives on incorporating genomics into mainstream healthcare in Australia. Their program of research looks at how best to prepare the health professional workforce.
They are requesting help in completing a research survey for medical specialists through the Australian & New Zealand Society of Blood Transfusion. The anonymous survey takes about 15 minutes to complete, and asks Australian specialists about their current and future clinical practice in genomics, and what training would best suit them to prepare to incorporate genomics.
NSWHP Blood Storage and Transport policy
(Please note that this is not an ANZSBT-endorsed resource. It has been included here to provide guidance on what other services are doing).
Public pathology laboratories in NSW were faced with the ongoing need to reduce red cell wastage while at the same time complying with best practice guidelines which required that any product that deviated even slightly from storage and transport temperatures and times, must not be transfused except at discretion of the laboratory director. NSW public pathology supports NSW Ambulance Aero-retrieval with blood packaged in multiple eskies containing O RhD) Negative red cells with loggers, which are deemed by guidelines to be “storage” rather than “transport”, with the high potential for non-compliance and wastage. There was nothing available locally to assist a laboratory director in making a decision about the fate of red cells which exceeded storage or transport specifications. NSWHP Transfusion Clinical Stream had therefore sought to provide some guidance to it’s transfusion laboratories by preparing a policy document (PD_012) to optimise the use of blood products within NSW public pathology laboratories. The PD referred to requirements of ANZSBT Guidelines for Transfusion and Immunohaematology Practice – Nov 2016 and to Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisary Committee (JPAC) Guidelines for Blood Transfusion Services. The PD has successfully standardised varied local laboratory practices across NSW, and been of significant assistance to laboratory directors to keep blood wastage low. This PD is provided courtesy of NSWHP as an example of a useful document for ANZSBT members to use to develop similar cell storage and transport policies, perhaps even at a national level.