National Blood Authority
AHA supported the National Blood Authority to improve the safety and quality of blood transfusion by analysing the haemovigilance systems and capabilities of the different states and territories across Australia.
Blood transfusion involves a complex chain of events with numerous opportunities for error. In Australia, the National Blood Authority (NBA) is continually seeking to improve transfusion safety and quality, and a number of measures have been introduced to increase both the safety of blood components for transfusion and the transfusion process itself.
Accurate data is essential to any safety and quality program. Across Australia, each state and territory had developed its own haemovigilance program and reporting processes, but there were no national standards.
The NBA established the Haemovigilance Project Working Group to facilitate the development of a national voluntary framework to capture, analyse and report serious transfusion mishaps and reactions in Australian hospitals.
The group developed a primary national minimum list of serious reportable adverse events, along with descriptive data about the adverse event, the implicated blood product, the patient and the facility. The reporting model included links to existing healthcare systems.
AHA was engaged by the National Blood Authority to:
Following the success of the project, the NBA engaged AHA to expand the analysis and reporting to include the NT and NSW.
The Serious Hazards of Transfusion (SHOT) program in the UK reported that mistransfusion (giving the wrong blood to the patient) accounts for the overwhelming majority of reported adverse events, and this result was mirrored by reports from other countries.