Action 7.07 Reporting adverse blood management events
National Safety and Quality Health Service (NSQHS) Standards in collaboration with the Australian Government, private sector providers, clinical experts, patients and carers.
It comprise of total 8 standards.
The main focus of this assignment is 7.07 standard.
This is associated with transfusion adverse events are reported to enable identification of previous adverse reactions or transfusion requirements and to drive important opportunities.
Critiquing the Evidence
Standard 7.07 were not written in the last 5-10 years, which makes it less reliable than the latest guidelines.
Another significant lack is that it overlooked clear guidance on which health services report adverse blood events to in each state and territory.
This also not supported the health service to report the event correctly and therefore not contributing to current data and reports appropriately
Real World application
Standard 7.07 is used within the healthcare settings, where the report of the adverse event is done.
Upon reported as an adverse event, it falls under “national haemovigilance criteria” and analysed by specialised team.
Nurses faces potential drawback in implementing this guidelines.
In such cases, education, training, etc. should be implemented.
Evidence Informed Recommendations
Most important recommendations is to replace the evidence supporting the standard with current literature, the guidelines from the Australia and New Zealand Society of Blood Transfusion.
Double checking requirements of blood products and a change in the definition of mild adverse transfusion events, according to Royal College of Nursing Australia are 2nd edition guidelines.
Rating the Evidence(TABLE)
| Recommendation | Evidence Level | Type of Evidence | Confidence / Justification |
| Replace outdated 2011 ANZSBT guidelines with the 2024 3rd Edition | A | National clinical guidelines (ANZSBT, 2024) | High – Nationally endorsed, peer-reviewed, and reflects most recent transfusion best practices. |
| Update supporting evidence in NSQHS Action 7.07 with Haemovigilance Report 2021–22 | A | Government report (National Blood Authority, 2022) | High – Recent, comprehensive national data across states; reflects improved monitoring of transfusion incidents. |
| Incorporate findings from STIR Annual Report 2022–23 into national reporting guidance | A | Government surveillance program report (DoH, 2023) | High – Timely national data set on adverse events, supports quality improvement and transparency. |
| Address incident underreporting by including staff education recommendations from qualitative study | B | Peer-reviewed qualitative study (Winsvold Prang, 2014) | Moderate – Identifies real-world barriers in reporting, but study is older and not specific to hospital settings. |
Rating the Evidence
Evidence was rated using a hierarchy of evidence model (e.g., NHMRC or JBI, 2024).
Most sources were Level A – recent, national guidelines or government reports (Department of Health, 2023; National Blood Authority, 2022).
One source rated Level B due to older date and different setting (nursing homes).
Ratings reflect strength, recency, and direct relevance to Action 7.07.
High confidence supports strong recommendations for the 3rd edition NSQHS Standards.
Conclusion
Action 7.07 is critical for transfusion safety through robust incident reporting.
Strong evidence base supports enhancing definitions, roles, and education.
National guidelines (ANZSBT, 2024) and reports (Department of Health, 2023; National Blood Authority, 2022) provide Level A evidence.
Qualitative insights (Winsvold Prang & Jelsness-Jorgensen, 2014) highlight behavioural barriers to reporting.
Evidence-informed updates can improve compliance, staff engagement, and patient outcomes in NSQHS (3rd edition).
References
ANZSBT (Australian & New Zealand Society of Blood Transfusion). (2024). Guidelines for the administration of blood components (3rd ed.). Royal College of Nursing Australia. https://www.blood.gov.au/
Department of Health. (2023). Serious Transfusion Incident Report (STIR) annual report 2022–23. Blood Matters. https://www.health.vic.gov.au
National Blood Authority. (2022). Australian haemovigilance report 2021–22: A summary of adverse events following transfusion of blood and blood products. https://www.blood.gov.au/sites/default/files/documents/2025-03/Haemovigilance%20Report%202021-22.pdf
NHMRC (National Health and Medical Research Council). (2024). NHMRC levels of evidence and grades for recommendations for developers of guidelines. https://www.nhmrc.gov.au
Winsvold Prang, I., & Jelsness-Jørgensen, L.-P. (2014). Should I report? A qualitative study of barriers to incident reporting among nurses working in nursing homes. Geriatric Nursing, 35(6), 441–447. https://doi.org/10.1016/j.gerinurse.2014.07.003
