A clear overview of the Blood Matters STIR system: what it reports, how to submit notifications, the role in national haemovigilance, and resources on hyperhaemolysis and TACO. Includes guidance on investigation forms, confidentiality and contact details.
The Blood Matters Serious Transfusion Incident Reporting (STIR) system is a centralised mechanism for Victorian health services to report and learn from serious transfusion-related adverse events. Its core purpose is to improve detection, management and prevention of harm associated with blood transfusion by collecting de-identified case information and producing recommendations to drive safer practice.
STIR collects notifications, generates investigation forms and shares de-identified feedback to participating services. The scheme also contributes data to a national haemovigilance effort, helping to build a broader picture of transfusion safety across jurisdictions.
What STIR does and why it matters
At its heart, STIR provides three practical services for health services and clinicians: a central reporting platform where serious adverse transfusion events can be notified and assessed by an expert panel; de-identified feedback about reported incidents so local teams can learn from events elsewhere; and an annual statewide report summarising trends and recommendations.
These outputs are intended to translate case-level learning into safer transfusion practices across hospitals.
Reporting pathway and confidentiality
To submit a notification, clinicians use the online e-form. The initial notification requests limited patient identifiers only, such as age and gender, while avoiding unique identifiers to maintain confidentiality. After a notification is received, Blood Matters issues an investigation form by email to the address supplied in the notification; this form supports local case investigation and may prompt follow-up queries if extra details are needed.
How to start reporting
If this is your first STIR report, contact Blood Matters to obtain a health service code: call 03 9694 0102 or email [email protected]. The confidentiality safeguards and de-identification processes are essential to encourage honest reporting and to allow sharing of lessons without compromising patient privacy.
Bulletins, posters and topic-focused guidance
STIR produces focused communications that highlight cases of interest and identify opportunities to change practice. Recent materials include STIR Bulletin No. 14, which discusses hyperhaemolysis, and updated resources on TACO (Transfusion Associated Circulatory Overload). These documents are intended both to raise awareness and to provide concrete tools clinicians can use at the bedside.
Hyperhaemolysis: what clinicians should know
Hyperhaemolysis is an uncommon but serious haemolytic transfusion reaction in which the patient’s haemoglobin falls below the pretransfusion level. Bulletin No. 14 focuses on distinguishing hyperhaemolysis from other haemolytic reactions and outlines risk factors that clinicians should consider when assessing a patient with suspected post-transfusion anaemia. The bulletin is available in Word and PDF formats and was updated on 26 May 2026.
TACO awareness and the updated checklist
Transfusion Associated Circulatory Overload (TACO) is one of the leading causes of death and major morbidity associated with transfusion, yet it is often preventable. STIR has revised the TACO checklist poster to support clinicians in assessing risk, implementing prevention strategies, and monitoring and treating patients who are vulnerable to volume overload. The updated poster files (Word and PDF) were released on 26 May 2026 and are freely available to download.
National context and learning from data
STIR feeds de-identified data into the national voluntary haemovigilance program coordinated by the National Blood Authority (NBA). The NBA provides reporting and governance frameworks that aggregate jurisdictional data to monitor serious transfusion-related adverse events across public and private health services. Reports produced by the national program are accessible via the NBA website and help inform policy and system-level improvements.
From reports to recommendations
Information gathered through STIR investigations is used to generate practical recommendations aimed at reducing transfusion-related risk. These recommendations are shared via bulletins, posters and the annual STIR summary. The intention is to close the loop between incident reporting and practice improvement so that similar events are less likely to recur.
Accessing STIR resources
Clinicians and health services can download the most recent bulletins and posters directly from the Blood Matters resources. For help with reporting, for a health service code or to request additional information, contact Blood Matters on 03 9694 0102 or email [email protected]. Using the e-form and following the investigation process helps ensure high-quality information is captured for both local learning and contribution to national haemovigilance.
By combining structured reporting, targeted educational materials and contribution to national datasets, STIR aims to reduce avoidable transfusion harm, raise clinician awareness of rare but dangerous reactions such as hyperhaemolysis, and promote practical strategies to prevent common complications like TACO.
