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Victoria

The Victorian public hospitals use the VHIMS for incident reporting. The outcome severity of an incident is measured by an Incident Severity Rating (ISR). The ISR is derived from the degree of impact, level of care and treatment required and has four ratings:

  • ISR1: Severe/death
  • ISR2: Moderate
  • ISR3: Mild
  • ISR4: No harm/near miss.

The STIR program collects and reviews transfusion related incident data for participating hospitals from VIC, TAS, NT and ACT.

Health services, on notification of an incident to STIR, provide a severity rating based on the VHIMS definition. Following expert review, a patient outcome is assigned that aligns with the ISR ratings. For the purpose of STIR, near miss and IBCT may be assigned a severity rating based on the realistic potential to result in unexpected death or permanent disabling injury.

To produce the clinical outcome severity required for the national haemovigilance reports as defined in the ANHDD, validated data is run through an algorithm based on the expert review severity rating and taking into consideration reported death and ICU admission due to transfusion (Figure 9).

STIR classification and ANHDD clinical outcome severity

Figure 9: STIR classification and ANHDD clinical outcome severity

Reporting requirements for ISR incidents

ISR incidents and sentinel events

  • Health services report all haemolytic blood transfusion reactions resulting from ABO incompatibility to the Department of Health Sentinel Event Program within three days of the incident occurring.

Report templates are available at: http://www.health.vic.gov.au/clinrisk/sentinel/ser

  • Heath services conduct RCA for each ISR1 incident or sentinel event.
  • The final de-identified RCA summary report is provided to the department within 60 days of notification.
  • The RCA findings should be documented on the RCA summary report which includes a Risk Reduction Action Plan (RRAP) and RCA Report Form.
  • The Department of Health reviews and feeds back on submitted RCAs. The de-identified RCA and health service recommendations are also sent to the STIR Expert Group for review and comment with any additional recommendations reported back to the health service by the Department of Health.
  • Health services are to confirm that they have completed the actions identified in the RRAP.
  • The RRAP feedback report template documenting the completed actions is to be submitted to the Department of Health.

Other ISR incidents

  • All other ISR1 and ISR2 incidents require a detailed investigation of the incident preferably using the in-depth case review methodology.
  • The investigation of ISR3 and ISR4 incidents can be undertaken at the local level but management responsibility for the investigation or review process must be assigned.
  • Reports and analysis of aggregate ISR3 and ISR4 incidents should be an agenda item for the ward, department or unit on a regular basis and are often reported to the hospital Transfusion Committee or equivalent.