This project supported the National Blood Authority (NBA) to improve the safety and quality of blood transfusion in Australia.
Blood transfusion involves a complex chain of events with numerous opportunities for error.
Over the past decade, a number of measures have been introduced to increase both the safety of blood components for transfusion and the transfusion process itself.
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).
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 was engaged by the National Blood Authority to:
Following the success of the project, the NBA engaged AHA expand the analysis and reporting to include Haemovigilance Reporting Capacity in NT and NSW.
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 was mirrored by reports from other countries.