Over the past decade, numerous measures have been employed to increase both the safety of blood components for transfusion and the transfusion process itself. Blood transfusion involves a complex chain of events, involving a diverse group of health professionals, with a number of opportunities for error. The greatest risks to patients from transfusion now relate to hospital-based steps in the process, particularly mistransfusion (transfusion of the wrong blood to a patient), The Serious Hazards of Transfusion (SHOT) program in the UK reported that mistransfusion accounts for the overwhelming majority of reported adverse events and this result is mirrored by reports from other countries.
In Australia, the National Blood Authority (NBA) is seeking to improve transfusion safety and quality. An important step in any safety and quality program is the analysis of data. The NBA is facilitating, through the Haemovigilance Project Working Group, the development of a voluntary framework to capture, analyse and report serious transfusion mishaps, and reaction in Australian hospitals.
A primary national minimum list of serious reportable adverse events has been developed, along with descriptive data about the adverse event, the implicated blood product, the patient and the facility. The planned reporting model will be linked to existing healthcare systems.
Across Australia, each jurisdictional Department of Health has developed its own haemovigilance program and reporting processes. Some have been in place for several years while others are still in their infancy. AHA has therefore recently been engaged by the NBA to:
- analyse the systems and capabilities of the Victorian, ACT and Tasmanian Departments of Health
- report haemovigilance data to the NBA
- develop a standardised process to allow the same analysis of other State/Territory systems and capabilities.
AHA was appointed by the NBA to conduct this important work based on:
- our experience undertaking projects in the blood sector
- our experience in and ability to develop detailed specifications for healthcare information systems,
- the extensive relevant experience of our consulting team.
Due to the success of the project the NBA engaged AHA to do an analysis of Haemovigilance Reporting Capacity in NT and NSW