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Australia's capacity to report haemovigilance data

Haemovigilance in Australia

Haemovigilance is a vital and integral part of modern transfusion medicine. In Australia, national haemovigilance reporting is voluntary (with the exception of sentinel events, see Appendix IV) but is seen as part of the professional duty of care for patient safety. The Australian government has recommended health service organisations participate in relevant haemovigilance activities conducted either locally or at state or national level from 1 January 2013 as part of NSQHS Standard 7.

Haemovigilance provides a very important source for identifying emerging trends in hazards related to blood transfusion. The quality of blood and blood products in Australia has reduced the recorded risks associated with the transfusion product itself. The major residual hazards of transfusion in Australia can be broadly divided into human errors and clinical reactions. In common with other OECD countries, such as the United Kingdom, New Zealand, Sweden and Canada, the risks to the safety of transfused patients in Australia have clearly been shown to occur predominantly in the hospital environment arising from human errors. For example, the majority of preventable transfusion errors and adverse events result from human error.

To support the continued development and alignment of state and territory haemovigilance and systems with the national reporting requirements, JBC endorsed the recommendations in the Initial Australian Haemovigilance Report 2008 and established a National Haemovigilance Program in 2008. The rationale for setting up the National Haemovigilance Program was to:

  • enable transfusion practice improvements
  • enable product improvements
  • identify contributory and comparator factors
  • place Australian transfusion risks into an international perspective.

The National Haemovigilance Program is implemented through the following initiatives:

  • the HAC
  • maintaining a national haemovigilance database and the ANHDD
  • publishing Australian haemovigilance reports
  • participating in IHN
  • promoting and reporting Australian haemovigilance at local, national and international forums
  • integrating the activities and output from the National Haemovigilance Program with relevant linked NBA activities including the development of patient blood management clinical practice guidelines, national educational initiatives, and developing the national patient blood management program.

In addition to the National Haemovigilance Program, haemovigilance is also supported at a national level by bodies involved in education and practice improvement, production of guidelines, product and service standards and accreditation:

  • Australian Commission on Safety and Quality in Health Care (ACSQHC)
  • Australia and New Zealand Society for Blood Transfusion (ANZSBT)
  • Australian Association of Pathology Practices (AAPP)
  • Australian Council on Health Care (ACHS)
  • Australian Haemophilia Centre Directors' Organisation (ACHDO)
  • Australian Nursing Federation (ANF)
  • Australian Private Hospitals Association (APHA)
  • Australian Red Cross Blood Service (Blood Service)
  • Australian Society of Blood Transfusion (ASBT)
  • BloodSafe eLearning Australia
  • Clinical Excellence Commission (CEC)
  • National Association of Testing Authorities (NATA)
  • National Coalition of Public Pathology (NCOPP)
  • National Health and Medical Research Council (NHMRC)
  • National Pathology Accreditation Advisory Council (NPAAC)
  • Royal College of Pathologists of Australasia (RCPA)
  • Therapeutic Goods Administration (TGA).

The NSQHS Standard 7 requires that health organisations ensure blood and blood product adverse events are included in the incidents management and investigation system:

  • 7.3.1 Reporting on blood and blood product incidents is included in regular incident reports
  • 7.3.2 Adverse blood and blood product incidents are reported to and reviewed by the highest level of governance in the health service organisation
  • 7.3.3 Health service organisations participate in relevant haemovigilance activities conducted by the organisation or at state or national level.

The Stewardship Statement outlines measures that Health Ministers expect all health providers to adopt within their organisation. This includes the requirement to manage blood and blood products in ways that ensure transfusion-related adverse event information is collected and managed according to jurisdictional requirements.

Case study 4: STIR end to end process for haemovigilance

Background

The Blood Matters Serious Transfusion Incident Reporting (STIR) system is the only standalone haemovigilance system in Australia. It receives voluntary reporting of blood related incidents and near misses from public and private health services in Victoria, Tasmania, the Australian Capital Territory and the Northern Territory using a semi-automated process. All cases reported to the STIR undergo an independent review/validation process to determine classification and assignment of imputability and severity. This review/validation is considered one of STIR's strengths, but it is time-intensive and adds complexity to the process.

STIR end to end process

To better understand the STIR System and identify areas for improvement, the STIR and NBA analysed the STIR haemovigilance review and reporting activities and produced a STIR end to end process map (Figure 8) which identified the following five steps.

Step 1: Assessing adverse events

The Health Service Quality and Safety Representative (Q&S Rep) reviews and investigates incidents reported to the Incident Management System prior to notification to STIR.

Step 2: Notification to STIR

The Q&S Rep notifies STIR of the incident through the completion and submission of an eForm linked on the Blood Matters website (https://stir.transfusion.com.au/).

Step 3: STIR investigation of reported adverse events

The STIR Secretariat conducts a scope assessment for the reported incident. The STIR Secretariat emails a relevant investigation form for the in-scope incident to the Q&S Rep for completion. The investigation form provides more detail about the incident such as product involved, where and when it occurred, contributing factors and outcome for the patient. The Q&S Rep is requested to complete the form within four weeks and return the form electronically to the STIR for review. The STIR Data Manager (DM) enters the de-identified data into an Access database.

Step 4: Validation/review of severity, imputability and causality

This step is the fundamental component of the STIR system. This process includes the review and validation of the incident by expert reviewers who volunteer their time. The review validates reports, and enables recommendations and tools to be developed to help health services understand and better manage serious transfusion reactions. The reported incident may undergo three levels of review:

  • Initial review

The STIR DM extracts the 15 earliest unreviewed adverse events from the Access database and copies the records into a review tool. A reviewer is selected to conduct the initial review. If the reviewer changes severity, imputability/causality or disagrees with the health service assessment of type of reaction the event will be flagged for further review.

The STIR DM merges the review data into a database and then conducts a consensus review to determine whether or not the report is available for feedback or requires further specialist or group review.

  • Specialist review

If the reviewer comes to a different assessment of the severity or imputability/causality or type of reaction, the report is referred to a specialist reviewer. The STIR DM extracts a subset of up to 15 records that requires specialist review and copies the records into a specialist review tool. A Specialist reviewer is selected to conduct the review. Following review the STIR DM merges the reviewed data into a database and then conducts a consensus review to determine whether or not the report is available for feedback or requires further group review.

  • Expert group review

If, after specialist review, consensus is not achieved then the event will be reviewed by the STIR Expert group. This is the final review to address all the issues for the records from previous review process(s). The reports will be available for feedback after this process.

Step 5: STIR feedback

The Blood Matters program publishes STIR de-identified aggregated reports and STIR sends summary reports to all reporting health services every six months for quality improvement purposes.

Conclusion

Haemovigilance reporting is now a national requirement for health services. The STIR expert case review process currently involves multiple business areas and includes detailed pathways to resolve the more complex cases. Analysis of data and feedback informs and assists health services to improve transfusion practice, meet reporting requirements and comply with the NSQHS Standard 7. Mapping the business process helps to demystify these pathways and identify areas for improvement, including future strengthening of the system and potential efficiencies.

Serious Transfusion Incident Reporting end to end process

Figure 8: Serious Transfusion Incident Reporting (STIR) end to end process, 2012–13

New South Wales

NSW is the most populous state in Australia with a population of just under 7.5 million in 2012–13. Supporting this population are over 200 public hospitals, a large percentage of which transfuse blood and blood products, as well as over 100 private facilities. Usage of fresh blood products in NSW accounts for approximately 30% of the National issue.

In 2006, the NSW Clinical Excellence Commission (CEC), in collaboration with NSW Health, launched the Blood Watch program to implement and support transfusion medicine improvements in NSW public hospitals. The Blood Watch Program provides a mechanism for system analysis and design related to the clinical use of blood and blood products, a key function of which is the review and analysis of haemovigilance-related information and data.

NSW public hospitals use a centralised incident reporting platform to report incidents and near miss events, including those related to the clinical handling, management and administration of blood and blood products. The current platform used is the Incident Information Management System (IIMS).

In keeping with the principles outlined in the National Haemovigilance Program, incidents and events are reported, investigated and managed locally, and the information is used within the context of an overall health system defined by the mandatory NSW Policy Directive PD2014_004 Incident Management. Incident management processes and system level analysis is undertaken at the state level by the Patient Safety team as a function of the CEC.

The definitions of transfusion-related incidents and adverse outcomes contained within IIMS pre-date those outlined in the ANHDD. Data extracted, once de-identified, requires review and re-classification prior to submission for inclusion in the National Haemovigilance Report. This is undertaken on a bi‑annual basis by the Blood Watch Program team and an expert clinical review group.

As IIMS contains entries relating to the clinical elements of the transfusion chain, as well as adverse outcomes from all blood and blood products (not just fresh products), only a small number of relevant incidents entered, approximately 15% are mapped and submitted for the National Haemovigilance report. All haemovigilance incidents are aggregated at the state level and are used to inform risk, identify opportunities for local improvements, and inform state wide improvement opportunities (such as the implementation in 2012 of the mandatory requirement for health care workers involved in transfusion to complete BloodSafe eLearning).

Learnings from the bi-annual review of the IIMS data, as well as the national haemovigilance reports and other international programs such as the Serious Hazards of Transfusion (SHOT) program in the UK, are currently being used to inform the build of the upgrade to the NSW reporting system. The upgrade, and new centralised reporting system, is planned for release in 2016.

An expert working group has been convened to support the development of the haemovigilance business rules for the new system. Work has progressed on ensuring the ability to capture data for inclusion in the national reporting program, in compliance with the ANHDD, whilst maintaining and supporting the ongoing reporting of all haemovigilance incidents that currently inform the system in NSW.

Victoria

Blood Matters is a collaborative between the Department of Health and the Blood Service with the goal of improving transfusion quality, safety and appropriateness of blood and blood products. The STIR system is one part of the Blood Matters program. Governance of the STIR system is provided by an expert group of clinicians with an interest in adverse event management and transfusion improvement, along with assistance from the Blood Matters secretariat, and it reports to the Blood Matters Advisory Committee (BMAC). STIR is a voluntary reporting system that collects haemovigilance data on events from participating public and private health services in VIC, ACT and NT (through memorandums of understanding). Victorian public health services report clinical incidents into a state‑wide reporting system, the Victorian Health Incident Management System (VHIMS) which includes blood‑related incidents. Categories of events reportable to STIR are classified as either clinical or procedural.

Clinical:

  • acute transfusion reaction (including anaphylaxis)
  • delayed transfusion reaction
  • transfusion‑associated graft versus host disease
  • TRALI
  • TACO
  • PTP
  • post‑transfusion viral infection
  • bacterial/other infection.

Procedural:

  • IBCT
  • wrong blood in tube (WBIT)
  • other near miss events.

In 2015 data collection will be expanded to include events related to cell salvage and Rh(D) Immunoglobulin.

The electronic system used to manage incident reporting data as part of STIR has been developed within the Blood Matters program. Health services submit an initial electronic notification through a web eForm to the STIR office. The STIR office then provides a detailed follow-up investigation form tailored to the type of event notified. This second level reporting by health services collects additional relevant detailed information specific to the event type, and is reported using an electronic Word form. Both forms are imported into the database through a semi‑automated process, providing timely review and follow up. Confidentiality is maintained by collection of limited patient information (such as age and gender only) and health services are identified by a code only known by the STIR office, which is not included in the expert review process.

From February 2006 to 30 June 2013, STIR received 1,207 notifications of transfusion episodes resulting in 1,221 adverse events and incidents, with 55 health services reporting at least one event. In 2011–13, 43 health services from VIC, ACT, NT and TAS reported 356 events. Based on information from the Victorian Admitted Episode Dataset, it is estimated for VIC that health services which have agreed to report (public and private) represent approximately 90% of the total blood transfusion activity. From 2006–13 clinical incidents events (acute transfusion reactions) comprise 49% of the reports. Procedural events account for approximately 43% of the events, and include incorrect blood component transfused (including transfusion of a unit intended for another patient, or which did not meet a patient's individual requirements, such as failure to provide irradiated components), 'wrong blood in tube' events and other 'near miss' events.

Reports are expected to be reviewed prior to submission to STIR. In most health services this occurs through review by the transfusion committee (or similar) or senior medical officer. The STIR program validates incident data through expert review. STIR review includes classification and assessment of imputability and severity rating. The expert review group is comprised of medical, nursing and scientific staff with an expertise and interest in transfusion. The review process is a key strength of the STIR program; it provides validity to the data submitted and recommendations for improved practice. ABO incompatible blood transfusions are also reportable to the Victorian sentinel event program, and a root cause analysis (RCA) approach for these events is reviewed by the STIR expert group, with comments and recommendations provided back to reporting health services through the sentinel event program.

Aggregate information from STIR is presented to BMAC and used to develop recommendations and educational resources for health services. All STIR reports from 2006 onwards are available on the Blood Matters website http://www.health.vic.gov.au/bloodmatters/tools/stir.htm. STIR regularly shares experiences and data locally, nationally and internationally at conferences, workshops and meetings. The implementation of the National Standards for accreditation has reinforced the importance of recognising, reacting to, and reporting transfusion adverse events. Having staff dedicated to support NSQHS Standard 7 increases awareness of and engagement with haemovigilance activities.

Queensland

QLD is a large and highly decentralised State, with an estimated resident population of 4.708 million in March 2014.[53] The State's use of blood and blood products is mostly provided across 16 Hospital and Health Services and 105 licensed private health facilities.

Queensland Health had a centralised haemovigilance system until early 2013. Under this system, data validation and analysis was conducted by clinicians in a corporate division of Queensland Health. The data presented in this report, for 2011–12, was a product of this centralised haemovigilance system.

The Queensland haemovigilance system was adapted in line with the new structural arrangements for public health services in QLD. Under these arrangements, Health Hospital and Health Services (HHSs) and licensed private health facilities continue to report incidents and, as required by NSQHS Standard 7, implement local haemovigilance activities, which may include:

  • completing follow up forms in response to blood-related incidents reported in local incident monitoring systems
  • entering haemovigilance data in a standardised spreadsheet
  • reviewing and validating haemovigilance data
  • providing de‑identified haemovigilance data for state and national haemovigilance reports.

In major hospitals with transfusion nurses, haemovigilance-related quality improvement activities are being implemented. Some hospitals without transfusion nurses have given the responsibility for monitoring and implementing haemovigilance activities to local patient safety officers.

Local action is supported by a guideline on haemovigilance data collection and analysis and a suite of tools (electronic haemovigilance forms and spreadsheet), to facilitate consistency in haemovigilance reporting and analysis processes across QLD. The Department of Health will coordinate data provision from health facilities to the NBA for national haemovigilance reporting.

Future plans for haemovigilance in QLD are to include haemovigilance reporting in the new statewide incident reporting system being developed by Queensland Health for use by HHSs.

Western Australia

WA is a jurisdiction with an estimated population of 2.5 million people that covers an area comprising some 2.5 million square kilometres. Approximately three quarters of the State's population reside in the greater Perth metropolitan area. Western Australia is serviced by both public and private hospitals that transfuse blood and blood products. These include a number of tertiary and major private hospitals located in the Perth metropolitan area and a network of general and regional public hospitals located in the metropolitan area and across rural WA. Several larger regional centres are also serviced by private hospital providers.

WA Health acknowledges the Statement on National Stewardship Expectations for the Supply of Blood and Blood Products including requirements for transfusion-related adverse event information to be collected and managed as part of appropriate stewardship of blood products and patient and product safety.

Currently, haemovigilance data in WA is collected and analysed on an individual hospital or health service basis. In WA public hospitals, transfusion-related incidents and adverse events are investigated at the individual hospital level and data collected and reported to hospital transfusion or blood management committees and/or hospital safety and quality committees. This can include collection of data and reporting on near miss events. Product-related reactions may also be reported through the state public pathology provider PathWest to the Blood Service.

Transfusion-related incidents and reactions may be classified according to defined outcome severity with incidents rated as major or severe requiring review by the highest governance level of the hospital. In WA public hospitals, clinical incidents classified as Severity Assessment Code 1 (SAC1), which includes sentinel events, or SAC2 are mandated to be reported via the WA Health Clinical Incident Management System DATIX CIMS. This online system operates across all public sector hospitals and health facilities providing a state-wide platform for the notification and management of health care incidents.

Private hospitals currently collect their haemovigilance data through their internal organisational quality and risk management systems. In WA, private licensed health care facilities are required to report all clinical incidents rated as SAC1 to the WA Department of Health. Transfusion-related incidents and adverse events are reviewed internally by hospital safety and quality and/or transfusion committees. Product-related reactions may be reported through private pathology providers to the Blood Service.

Depending on the hospital, investigation of transfusion-related adverse events and collection of data for internal hospital reporting is undertaken by a variety of staff. These include hospital transfusion and PBM nurses, transfusion coordinators, laboratory scientists and consultant medical staff. These individuals provide leadership in the area of haemovigilance by maintaining systems for the investigation, review and management of transfusion-related adverse events, providing education for hospital staff and aligning transfusion practice with relevant national clinical guidelines and the NSQHS Standard 7.

The BloodSafe e-Learning program is promoted as an important training and education program for staff involved in transfusion in WA hospitals. WA also continues to promote the principles of PBM as a standard of care state-wide. Although formalised programs are changing in 2015, the standard of care/change in practice continues throughout the state and WA remains a resource for PBM excellence. PBM is the essence of evidence based practice regarding anaemia diagnosis, treatment and avoidance of unnecessary transfusion.

In early 2015, WA established a State Haemovigilance Committee. The Committee has broad representation from public and private sectors. A role of the Committee is to assist WA with decision making and implementation of a local model for haemovigilance. This includes consideration of a reporting tool and process, accessible state-wide, for the collection of haemovigilance data aligned with ANHDD. Implementation is intended to facilitate the generation of state-level haemovigilance reports and provision of WA data for national reporting as well as meeting the requirements of NSQHS Standard 7.

South Australia

SA has a population of 1.7 million which accounts for approximately 7.09% of the national population. SA is serviced by the nine public metropolitan hospitals and network of country hospitals and health services comprising SA Health, and the private sector. The laboratories supporting these sites are SA Pathology (comprising 7 metropolitan and 9 regional public laboratories) and four private pathology providers.

SA Health continues to use the online Datix Safety Learning System (SLS) for reporting and managing incidents and consumer feedback across the public sector. The ANHDD was taken into consideration during the development of the SLS to facilitate national haemovigilance reporting in addition to meeting general hospital requirements. The quality of the data in SLS has improved since its implementation as a consequence of increased user knowledge of the software and improvements in reporting options. Alignment with the ANHDD has improved with the recent inclusion of mandatory fields for age, sex and date of birth for all adverse events. However, review of SAC scores and free text fields is still required to interpret events and assign an ANHDD classification to each incident reported.

The private sector utilises various incident management systems which are reviewed internally via safety and quality and/or transfusion committees. At present, there is no combined registry of public and private transfusion-related adverse events.

The collection and analysis of haemovigilance data in SA is undertaken on an individual hospital/health service basis. BloodSafe Transfusion Nurse Consultants, who cover the major metropolitan hospitals and country regions, receive notification of all incidents classified under 'transfusion of blood-related problems' and participate in the reporting, review, investigation and follow-up of adverse and near-miss events.

SLS reports are generated for the hospital Blood Management Committee to inform activities in the Transfusion Quality Improvement program, including monitoring organisation-wide risk. SA Pathology is advised of blood and blood product incidents via the completion and submission of the SA Pathology Notification of Transfusion Reaction form as well as via the SLS notification system. SA Pathology is responsible for reporting to the Blood Service where appropriate. The national haemovigilance data submission from SA is limited to adverse events reported from across SA Health.

The SA Department for Health and Ageing mandates reporting of haemolytic blood transfusion reaction resulting from ABO incompatibility sentinel events through a separate sentinel event reporting process encompassing both public and private hospitals. All actual SAC1 incidents must be escalated to the Chief Executive Officer of the Local Hospital Network (LHN). In addition, SAC1 and 2 incidents are reviewed by the local Incident Review Panel or the Mortality Review committee. Recommendations arising from such reviews are directed to the relevant Blood Management Committee Chair for further action.

SA Health does not currently maintain a transfusion specific jurisdictional expert group whose role is to review, classify and assess adverse events, and validate data. Significant events are referred to general hospital or SA Health committees for review. The BloodSafe program and staff, however, continue to make a significant contribution towards blood transfusion safety and quality improvement. The work of BloodSafe Transfusion Nurse Consultants in public and private hospitals is aimed at:

  • promoting the appropriate use of blood and blood products
  • providing education on the safe administration of blood and blood products
  • conducting audits of appropriate use of blood and blood products and
  • developing tools to assist in the management, prescribing and administration of blood and blood products.

There are currently a number of haemovigilance-related activities underway that are focused on system, education and quality improvement:

  • The Department has been monitoring the utilisation of red blood cells by inpatients since 2006 through the SA Blood Utilisation Study. The information from this study has been incorporated into a Reporting Tool which allows major metropolitan hospitals to better understand their red cell usage patterns.
  • The Enterprise Patient Administration System (EPAS) currently being implemented across SA Health requires the development of blood and blood product transfusion orders sets. A transfusion working group is providing expert medical, scientific and nursing input into the prescribing and ordering requirements for blood and blood products. Key factors in the development include clinician friendly order sets meeting current national transfusion guidelines and legislative requirements.
  • The BloodSafe Transfusion Nurse Consultants are conducting audits to monitor variability in ordering practices and compliance with Standard 7 haemovigilance activities as part of each hospital's Transfusion Quality Improvement program.
  • A BloodSafe guide for Transfusion Nurses is under development, the aim of which is to ensure a standardised and consistent procedure for investigating, documenting and reporting transfusion-related incidents.
  • The SA Blood Management Council has recommended that all medical, nursing, and support staff complete training provided by BloodSafe eLearning Australia with the aim of improving the recognition and reporting of adverse events.

The system for the investigation, review and management of reported blood and blood component incidents/adverse events in SA is considered effective due to the collaborative efforts of the SA Department for Health and Ageing, the Blood Service, the SA BloodSafe Program and pathology services. Some reporting gaps remain in terms of both the completeness of individual reports and the overall system coverage across SA Health.

Future plans for haemovigilance in SA include:

  • development of EPAS order sets/pathways for the investigation and management of serious transfusion-related adverse events, critical bleeding and antenatal
  • further engagement of the private sector in haemovigilance activities.

Tasmania

In TAS, quality and safety activities are undertaken by the blood transfusion team at each major public hospital supported by the Hospital Transfusion Committee (HTC) and local safety and quality governance. TAS is a participant in the Victorian Haemovigilance Program: 'Blood Matters'. This includes reporting to the STIR system, which is administered by the Victorian Department of Health. Tasmanian hospitals are active participants in STIR and have two representatives on the STIR Expert Group.

A state‑wide incident reporting system operates across all public sector hospitals and health facilities. In 2013-14 the Electronic Incident Management System (EIMS) was replaced by the Safety Learning and Reporting System (SLRS). The new system is used at local and state-wide levels to report and manage all health care incidents as a critical component of quality improvement. When the scoping process for the replacement system was undertaken it was hoped that the new system would support direct capture and transfer of data to the STIR system but this has not been possible. Reporting to STIR remains a separate reporting process as the two systems are not aligned. Data is reported back to TAS by STIR and following review of the annual data TAS authorises STIR to report Tasmanian data to the NBA for the purposes of the National Haemovigilance Program. The provision of Tasmanian data to STIR remains the most practical option for reporting at a national level.

Reporting to SLRS is a mandatory requirement in all Tasmanian public sector hospitals. SLRS provides all public hospitals with a consistent, standard approach to incident reporting. Blood-related incidents represent approximately 1.4% of the total number of incidents reported. It is estimated that the private hospitals in TAS represent approximately 10% of the total transfusion activity in the state. All private hospitals record incidents, including blood-related incidents, to their own risk management systems, and recently some private hospitals have commenced reporting to STIR.

Many haemovigilance activities are coordinated by Blood Transfusion Nurses with positions now in place at each of the four major Tasmanian public hospitals. Blood Transfusion Nurses were funded following commencement of the national blood arrangements in order to contribute to jurisdictional requirements of the National Blood Agreement. The role of these positions includes education of clinical staff, development of policies and guidelines, conduct of audits of blood product utilisation and incident reporting and monitoring. Nursing staff undertake the required training in transfusion practice in order to meet the mandatory competency requirements. There is considerable clinical commitment to haemovigilance in TAS which is reflected in local governance and activities, participation in STIR and involvement in national clinical committees. There are good links with the Blood Service regarding haemovigilance activities.

Recent initiatives include representation from the major private hospitals on the state-wide Blood Management Group, strong promotion of the BloodSafe e-Learning program as an essential training component for all hospital staff involved in transfusion and the introduction of the Single Unit Policy.

Future haemovigilance strategies include:

  • further engagement of the private sector in haemovigilance activities
  • inclusion of haemovigilance reporting as a standing item on the agenda for the state-wide Blood Management Group meetings.

Australian Capital Territory

The ACT is a small jurisdiction with a population of 384,000 people, although the complete catchment covers an extensive area of south-eastern NSW that encompasses a total population of well over 500,000. The ACT is serviced by 2 public and 4 private hospitals that transfuse blood and blood products.

ACT Health aligns well to the Stewardship Statement's principle in regards to collating and managing haemovigilance data. This has been facilitated through the ACT's cross-jurisdictional collaboration with Blood Matters, Victoria and has enabled participation by ACT in the Blood Matters STIR system. The ACT's public hospitals use the RiskMan general incident reporting system to collect haemovigilance data. The reporting is mandatory if an incident is identified as a sentinel incident. Incidents are classified according to the defined severity of the outcome. The incidents rated as major or extreme outcome will require review by the highest governance level of the hospital. The system captures blood and blood product-related incidents including near misses. The classification of the incidents aligns with the STIR criteria and ANHDD.

The private hospitals currently collect and benchmark their haemovigilance data through their internal organisational quality and risk management systems.

ACT haemovigilance data, once released for the national haemovigilance report has already undergone a robust validation through a process of review and re-assessment of imputability ratings by an expert STIR panel comprised of medical and nursing clinicians and laboratory scientists (including a clinical expert from the ACT). Although the de-identified data are held and reported back to the ACT by STIR, the ACT reports into the National Blood Authority's (NBA) national haemovigilance program depending on its own assessment.

The ACT Transfusion Nurse endeavours to promote and sustain a jurisdictional approach to haemovigilance across the entire ACT health sector and has been instrumental in aligning transfusion practice across the Territory with the NBA's Patient Blood Management Guidelines and the NSQHS Standard 7.

The Transfusion Nurse provides clinical leadership in the area of haemovigilance by maintaining a robust system for the investigation, review and management of transfusion-related adverse events, providing education for staff and patients across the ACT, and the development and implementation of clinical policy aligned to national guidelines.

The BloodSafe e-Learning program is strongly promoted as a fundamental and essential training component for all staff involved in the transfusion chain at all hospitals across the ACT.

Future plans for haemovigilance in the ACT include:

  • introduction of the Single Unit Policy for ACT Health during 2014–15
  • working towards a robust data linkage platform for all blood and blood product usage
  • alignment and further promulgation of the Patient Blood Management suite of national guidelines.

Northern Territory

The Northern Territory Government (NTG) health services' haemovigilance system includes the following elements:

  • RiskMan electronic incident management system
  • Transfusion reaction reports
  • Transfusion Incident Review Group (TIRG)
  • Blood Matters STIR system.

All NTG hospitals use a centralised incident reporting system, the RiskMan electronic incident management system, as the only incident reporting tool. The NT Health Incident Management Policy and NT Health Incident Management Guide require NTG health staff to report all incidents and near‑miss events on RiskMan.

RiskMan has a specific classification for blood transfusion incidents. There are five categories under the blood transfusion classification: administration, transfusion reaction, blood product, documentation and massive transfusion, with additional sub-categories. The RiskMan system flags any transfusion incidents which are reportable to STIR. If an incident is reportable to STIR, a blood management extension is generated. The blood management extension captures the additional information required for an initial STIR report. Incidents reportable to STIR are:

  • acute transfusion reaction
  • delayed transfusion reaction
  • transfusion‑associated graft versus host disease
  • transfusion-related acute lung injury
  • transfusion associated circulatory overload
  • post-transfusion purpura
  • post‑transfusion viral infection
  • bacterial/other infection
  • incorrect blood component transfused
  • wrong blood in tube.

The NT transfusion clinical nurse consultant (CNC) submits initial STIR reports electronically or by email, and the second level STIR reports and investigations are completed by either the transfusion CNC or a hospital quality coordinator.

In NTG hospitals a transfusion reaction report is issued with all fresh blood components. If a transfusion reaction occurs, the transfusion reaction report is completed in addition to the RiskMan report. A copy of the transfusion reaction report is sent to the laboratory with any requested specimens.

The TIRG is an expert group consisting of medical, quality, nursing and scientific representatives. The group meets monthly to review all transfusion‑related incidents. TIRG members are alerted by email when a transfusion‑related incident is reported on RiskMan. The group:

  • collates and analyses transfusion incident data
  • ensures serious transfusion incidents are investigated appropriately
  • coordinates RCAs if required
  • ensures transfusion incidents which meet the STIR criteria are reported to Blood Matters
  • makes recommendations for transfusion practice improvement.

The TIRG reports quarterly to the NT Transfusion Committee. The five NTG hospitals participate in voluntary haemovigilance reporting to the Blood Matters STIR system through a memorandum of understanding between the Victorian Department of Health and the NT Department of Health. Each event reported to STIR is reviewed by the STIR expert group which is comprised of medical, nursing and scientific staff with expertise in transfusion (including a medical expert from the NT). Aggregate de‑identified haemovigilance data is presented in STIR annual reports and is submitted directly to the NBA.

The transfusion CNC is the chair of the TIRG and provides clinical leadership in haemovigilance across all five NTG hospitals. The transfusion CNC also coordinates transfusion education for clinical staff and is responsible for developing and maintaining local guidelines which align with international and national standards, including the Australian Commission on Safety and Quality in Health Care National Safety and Quality Health Service (NSQHS) Standards. The NT executive sponsor for NSQHS Standard 7 works closely with the transfusion CNC and the NT Transfusion Committee to strengthen the NT focus on blood safety.