Blood Matters better safer transfusion program

1
Blood Mattersbetter safer transfusion program
Essential elements of the Serious Transfusion
Incident Reporting system (STIR) Part 1 Lisa
Stevenson
2
Haemovigilance

• A system of surveillance and alarm, which
  encompasses all steps of the transfusion process,
  from blood collection to the follow-up of
  recipients
• Debeir J, Noel L, Aullen J, Frette C, Sari F, Mai
  MPV, Cosson A
• Vox Sang 1999 77 77-81

3
Introduction Serious Transfusion Incident
Reporting System (STIR)

• Statewide reporting system in private and public
  hospitals links with sentinel events program
• Collects serious adverse events and near misses
• Measure and monitor practice
• Make recommendations for better, safer practice
• FRESH blood products (red blood cells, fresh
  frozen plasma, platelets and cryoprecipitate)
• From volunteer or family donors or autologous
  collections

4
SHOT The Serious Hazards of Transfusion Scheme

• Launched in November 1996 UK
• Voluntary, confidential, anonymous
• Aims to capture data on major complications of
  transfusion

5
The Issues in TransfusionData from the SHOT
report 2007.
6
Near miss events SHOT 2005 n1358
Sample errors
Request errors
7
STIR Notified adverse events 2006-07
Data 2006-07
8
Products Implicated
reported incidents involved more than one
product unable to determine which product was
involved Issue data is Victoria and Tasmania
(Data ref ARCBS 2006-2007)
9
Actual adverse events are only the tip of the
iceberg, and are far outnumbered by near-miss
events!
Battles JB et al. Arch Pathol Lab Med
1998122231-238
10
Near Miss Events STIR

• Definition
• Any incident, that had the potential to cause
  harm, but didnt due to timely intervention and
  or luck or chance. For example any incident which
  is recognised before transfusion took place but
  which, if undetected, could have resulted in the
  determination of wrong blood group, or issue,
  collection, or administration of an incorrect,
  inappropriate or unsuitable component.

11
Wrong blood in tube (WBIT)

• Definition
• A special category of near-miss event, where it
  is detected that the labelled blood sample has
  been collected from an incorrect patient, however
  the transfusion did not proceed

12
Recognising an event

• The initial form (red/e form) has a summary of
  the main features and diagnostic tests.
• Definitions are provided in the guide, pages 9
  10
• Incorrect blood component transfused (IBCT)
• Acute transfusion reaction excludes acute
  reactions due to IBCT
• Delayed transfusion reaction occurring gt24 hours
  post-trfn
• Transfusion-Related Acute Lung Injury (TRALI)
• Transfusion-Associated Graft-Versus-Host Disease
• (TA-GVHD)
• Post-transfusion purpura (PTP)
• Transfusion-transmitted infections (bacterial,
  viral, parasitic)
• Near misses
• Wrong blood in tube a special category of near
  miss

13
Sentinel Events

• if there is an event that fits within the
  sentinel event program
• ABO incompatibility
• other-catastrophic event
• continue to report it through the sentinel event
  program, where a Root Cause Analysis is conducted
• STIR are notified of the sentinel event from the
  sentinel event program and are asked to review
  the healthservice recommendations

14
Flowchart (initial red form) p.7
Step Action
Responsibility of
Transfusion event reported on general
hospital-wide incident form. See NOTE 1.
Step 1
Clinical Staff
Quality/Risk Manager will receive the report
Step 2
Quality/Risk Manager
BeST Serious Transfusion Incident Report
completed and forwarded to 1. BeST Office
(within 3 business days.) AND 2. Relevant
hospital staff and committees. See NOTE 3 for
sentinel events.
Hospital Transfusion Contact
Step 3
Step 4
Relevant hospital staff and committees. Also,
ARCBSa notified if appropriate.
Blood Matters central office
AND
15
Flowchart Second report (blue)
Step Action
Responsibility of
Blood Matters forwards relevant second layer of
form (within one week) (for more detailed data).
Step 5
BeST
Completion of second layer form
conducted/arranged by hospital transfusion
contact and forwarded to Blood Matters (within
four weeks). RCAb arranged if appropriate.
Quality/Risk Manager
Step 6
Incident data entered by Blood Matters into
database.
BeST
Step 7
Data verified and collated by expert STIR group
and reported back to hospitals on trends.
BeST
Step 8
16
Organisational readiness checklist

• To be completed by the health service
• The purpose is to ensure that systems are in
  place prior to commencement of the incident
  reporting scheme
• Is included in the guide

17
Organisational readiness checklist

• Includes
• senior management commitment
• a hospital-wide incident reporting policy (that
  includes, transfusion incidents)
• operational management aspects need to be in
  place (eg a transfusion committee or equivalent
  with clear reporting lines, clarity on roles and
  responsibilities)
• Serious transfusion incident response (policy and
  procedures enable staff to identify an incident
  and know the reporting mechanism)

18
Notification Form

• both an e form and a paper based form are
  available via the Blood Matters website to notify
  of a serious transfusion incident to STIR

19
STIR e form www.health.vic.gov.au/bloodmatters
hospital code aligned with the Victorian
sentinel event program
with nature of incident may enter one or more
categories but must select suspected or confirmed
for each category.
reports can be entered by any clinician or
manager, Quality department should be made aware
of a report entered into STIR.
20
STIR e form
21
Completing the Second form

• This form will assist with your investigation of
  the adverse event at this stage this is a paper
  based system but with work in progress for an
  electronic form.
• Timelines for this form is four weeks from date
  of receiving.

22
Completing the second form
23
Where to get help

• Contact the Blood Matters-better safer
  transfusion program
• Lisa.Stevenson_at_dhs.vic.gov.au 03 9096 0476
• Karen.Botting_at_dhs.vic.gov.au 03 9096 9037
• Stir_at_dhs.vic.gov.au
• STIR guide available
• on the website

24
Thankyou
Acknowledgments and thanks to STIR expert
group Blood Matters-better safer transfusion
program Department of Human Services and
ARCBS and the reporting hospitals of Victoria and
Tasmania.