APPENDIX IV: NSW HAEMOVIGILANCE DATA FOR 2009-10 AND 2010-11

NSW is committed to contributing to a National Haemovigilance Program and the CEC has been collecting and analysing information on transfusion-related adverse events in public hospitals since 2004-05. Information is reported voluntarily via the electronic IIMS which was designed to capture information relating to a range of incidents. IIMS is not a specific haemovigilance reporting system and as a result many of the expected haemovigilance-specific data fields are not included within the IIMS incident classifications.

Those incidents reported into the blood/blood product category Principal Incident Type are included in IIMS reports regularly released by the CEC. In order to derive additional information regarding adverse transfusion events, the CEC performs a targeted analysis of the free text description of adverse events provided within the blood/blood product category. The criteria for this analysis are the incidents and complications identified in the ANHDD. The results of the analysis are reported annually to the NSW Blood Clinical and Scientific Advisory Committee and biennially to the NBA.

The number of incidents reported in IIMS under the blood/blood product category for 2009-11 that meet the haemovigilance data dictionary criteria are provided in Table 41 and Table 42.

In 2009-10 the total number of incidents entered under the IIMS Blood Category was 1826:

16.7% (n=305) of entries were labelled as Incidents
10.9% (n=200) of entries were labelled as Complications
72.3% (n=1,321) of incidents recorded entered under the IIMS Blood Category did not meet the European Haemovigilance Network definitions. These included documentation issues (n=642), occupational health and safety (n=86), needle stick injury (n=9), postpartum haemorrhage (n=27) and wastage (n=183).

In 2010-11 the total number of incidents entered under the IIMS Blood Category was 1,865:

67.1% (n=1,253) of all entries were labelled as Incidents
14.8% (n=186) of the 1,253 incidents were labelled as Complications.

It should be noted that currently NSW does not assign imputability scores into the IIMS reporting system. IIMS in its current state cannot provide the level of detail required for true haemovigilance to be recorded due to the limitations in IIMS functionality, categories and sub categories. Furthermore, the reliability of data on reported incidents in the blood/blood product category is dependent on the staff member recognising that a significant adverse event has occurred and initiating the incident report. Continuous education in relation to the recognition of transfusion-related adverse events is required.

A key focus in NSW in relation to reducing adverse events associated with transfusion has been to reduce inappropriate transfusion. The Blood Watch program commenced in 2006 and over the last six years there has been at least a 10% reduction in red blood cell transfusions for inpatients in NSW public hospitals. A primary focus for the program continues to be improving all aspects of identification, treatment and reporting of adverse transfusion-related events.

Note: In 2009-10 NSW was divided into Area Health Services, and then in 2010-11 NSW was divided into Local Health Districts.

**Table 41:** NSW haemovigilance data for 1 July 2009 to 30 June 2010
Incidents	Number of reports
Dispensing of expired or unsuitable component	16
Dispensing of expired or unsuitable component and Fever >39^{^o}C	0
Incorrect administration of blood or component dosage	17
Incorrect administration procedure	40
Incorrect equipment	22
Incorrect infusion rate	26
Mislabelled	153
Taking blood sample from incorrect patient	1
Wrong blood dispensed	5
Wrong blood or component administered to wrong patient	0
Wrong component ordered	1
Wrong patient	24
Total	305
Complications	Number of reports
Transfusion-transmitted infections
2.1.2 Bacteria/Infection
Transfusion reaction - positive bacteria growth on culture	1
Transfusion reaction >39^{^o}C - RBC	10
Immune Complications of Transfusion
2.2.3 TRALI
TRALI - transfusion-related acute lung injury	3
2.2.7 Anaphylactic reaction
Anaphylactic reaction	5
2.2.9 Alloimmunisation
Transfusion reaction - antibodies formed	0
Cardiovascular and Metabolic Complications of Transfusion
Transfusion reaction - fluid overload	4
Unspecified Transfusion reaction
Unspecified Transfusion reaction	150
Transfusion reaction - rash	27
Total	200

**Table 42:** NSW haemovigilance data for 1 July 2010 to 30 June 2011
Incidents	Number of reports
Dispensing of expired/unsuitable component	19
Dispensing of expired/unsuitable component plus fever >39^{^o}C	1
Incorrect administration of blood or component dosage	8
Incorrect administration procedure	46
Incorrect equipment	19
Incorrect infusion rate	15
Mislabelled/Documentation/Consent	1,116
Taking blood sample from incorrect patient	13
Wrong blood dispensed	5
Wrong blood or component administered to wrong patient	6
Wrong patient	5
Sub-total	1,253
n/a - does not meet ANHDD criteria	612
Total	1,865
Complications	Number of reports
ABO incompatibility	4
Anaphylactic or anaphylactoid reaction	8
DHTR	3
Immediate haemolytic transfusion reactions (other than ABO)	1
PTP	1
Severe allergic reaction	39
FNHTR	115
TRALI	3
TTI	2
TACO	10
Total	186