Tasmania
In TAS, all public hospitals use the SRLS to report clinical incidents. Incidents including blood related incidents are classified using a SAC. The SAC is based on the immediate consequence of the event and the likelihood of recurrence of incidents. The SAC has four scores and SAC1 incidents include sentinel events. ABO incompatibility is a sentinel event for blood and blood products.
- SAC1: Extreme risk
- SAC2: High risk
- SAC3: Medium risk
- SAC4: Minimum risk
Tasmanian public hospitals also participate in the STIR Program for national haemovigilance reporting. Table 44 shows that the SAC aligns with the clinical outcome severity defined in the ANHDD. However, the mappings from the SAC scores to ANHDD categories are not straightforward because the SAC scores are difficult to interpret. In contrast, the consequence categories (serious, major, moderate, minor, minimum) which are used to calculate the SAC scores can be mapped to the ANHDD categories.
| SAC | ANHDD |
|---|---|
| SAC1 | Death Life threatening |
| SAC2 | Severe morbidity |
| SAC3 | Minor morbidity |
| SAC4 | No morbidity |
Reporting requirements for SAC incidents
SAC1 and SAC2 incidents
- Health services report all SAC1 and SAC2 incidents within 24 hours of occurrence.
- The incidents are referred to a Weekly Incident Panel comprising staff from the Safety and Quality Unit. This panel decides whether the event should go before the Serious Incident Panel for review.
Other SAC incidents
- Health services provide a report on SAC3 and SAC4 incidents through routine Core Reports.
- SAC3 and SAC4 incidents, which used to be managed by the Transfusion Nurse Consultant, are now required to be managed by the Nurse Unit Manager of the area where the incident occurred.