National blood quality and safety initiatives
Haemovigilance has become a more routine part of clinical practice in Australia. The data to date suggests a focus on those events that are most common (such as FNHTR and severe allergic reactions) and that cause the greatest numbers of severe patient outcomes (such as TACO and anaphylactic reactions).
In relative terms, the Australian data suggests that TACO and TRALI, which account for disproportionate numbers of life threatening and severe morbidity events, are likely under‑reported. National quality and safety initiatives should be developed with the aim of helping clinical staff to recognise and manage these events and support alignment of hospital transfusion practice and incident reporting with the NSQHS Standard 7.
| Recommendation | Who is Responsible | Proposed Strategy | How that will be measured | |
|---|---|---|---|---|
| 1 | Promote the recognition and management of transfusion-related adverse events | NBA; JBC; Blood Service; ANZSBT; State and territory departments of health; Hospital Administrators; Hospital educators; Relevant professional Colleges and Societies |
Establish a working group to rescope and redevelop the Guidance on Recognition and Management of Acute Transfusion-Related Adverse Events (the Guidance) Publish the Guidance on the NBA website and incorporate it into the eLearning module |
The Guidance redeveloped by the working group the Guidance published, distributed and evaluated by the NBA An eLearning module based on the Guidance developed |
| 2 | Implement programs at the national, state and local hospital levels to improve reporting of serious adverse events | NBA; JBC; State and territory departments of health; Hospital Administrators; Hospital educators; Relevant professional Colleges and Societies |
The NBA and HAC will continue to engage with key stakeholders as part of the ongoing national haemovigilance and stewardship programs The outcomes for Recommendations 6, 9 and 10 will also contribute to improving reporting of serious adverse events |
The Guidance implemented The eLearning module developed and used by JMOs Reporting rates increased |