Serious Transfusion Incident Report

State Government of Victoria, Australia

Department of Health

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The Serious Transfusion Incidents Reporting (STIR) system is a central reporting system for serious adverse events with transfusion of blood or blood components including near-miss incidents.

Please use this form to report serious incidents with transfusion of fresh blood and blood components. Confidentiality of data is fundamental to the success of this scheme. We have not requested unique patient indentification details. We will contact you to obtain additional details if necessary.

Key details of incident

Hospital Code

Patient Details

Gender

Male Female

Age

Description of Age

Details of product

Red Cells Platelets Fresh frozen plasma Cryoprecipitate Other

you may check more than one box

Date and time of implicated Transfusion or date of Sample

Nature of Incident

Clinical Reaction

Acute transfusion reaction

Delayed haemolytic transfusion reaction

Delayed serologic transfusion reaction

RhD Isoimmunisation event

Transfusion ‐ associated circulatory overload (TACO)

Transfusion ‐ associated graft‐versus host disease (TA‐GVHD)

Transfusion ‐ related acute lung injury (TRALI)

Transfusion ‐ associated dyspnoea (TAD)

Post ‐ transfusion purpura (PTP)

Bacterial/other infection

Post transfusion viral infection

Procedural

Incorrect blood component

Wrong blood in tube (WBIT)

Other near-miss incident

Procedural – other

RhD administration error

Cell salvage

Has your hospital blood bank/pathology provider been informed?

Yes No

Patient Outcome

No obvious clinical problem - Severity rating 4

Morbidity due to an adverse event - Severity rating 3-2

Death or major morbidity following adverse event (sentinel event) - Severity rating 1

Comment on patient outcome

Reporters Details

First Name

Surname

Position Title

Organisation

Postal Address

Date of Report

Email Address

Telephone Number

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