Background and Aim The STIR (Serious Transfusion Incident Reporting) voluntary haemovigilance system developed by the Blood Matters program commenced with a pilot in 2006.Hospitals and laboratories from Victoria, Tasmania, the Northern Territory and the Canberra Hospital in Australia now participate.The system aims to:· Measure and monitor serious transfusion incidents, including near misses, relating to administration and handling of fresh components and pretransfusion samples.· Derive recommendations for better, safer transfusion practice and disseminate these to health services, state and federal governments and the Australian Red Cross Blood Service.Method, Results and Conclusions Since 2006 STIR has been notified from 51 institutions of 998 transfusion episodes resulting in 1009 adverse events (In 2009-10, 214 events were reported with a denominator of 440,591 blood components issued, frequency of event 1∶2058).The majority (55%) were associated with red cells and acute reactions were the most frequently reported event type 50 per cent (n=496)).Procedural errors, including near misses accounted for 43% of all events, with "wrong blood in tube" the most common of these at 25% and "incorrect blood component transfused" at 7% events, including 6 ABO incompatible transfusions.No deaths related to the events were reported.Reporting is a two-step process, with initial notification followed by an in-depth investigative form tailored to the type of event reported.During 2010-11 further steps were taken towards online reporting and automation of data management to simplify the process and improve the quality of data.Case review at an institutional level (e.g.by local transfusion committee) prior to reporting to STIR also contributes to data quality and completeness.All cases are reviewed by members of a multidisciplinary expert panel.A biennial report of general demographics and deidentified case studies is utilised to disseminate information widely to health services and availably publicly.Its aim is to provide recommendations and safety tips, to assist health services to improve local transfusion practice.Although many events were unavoidable providing that the transfusion was appropriate, the number of "near misses" and incorrect blood component transfused highlights the potential for serious consequences and need for ongoing practice improvement.