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Serious Hazards of Transfusion (SHOT) Annual Report 2007

Serious Hazards of Transfusion (SHOT)
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Serious Hazards of Transfusion
 Blood Transfusion
 Transfusion Reaction
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NHS Blood and Transplant
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SHOT-Report-2007.pdf
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http://hdl.handle.net/20.500.12417/1360
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Abstract
The issues surrounding education and training raised in the 2006 report are emphasised by the findings for 2007. There remains evidence that junior doctors are making critical decisions without adequate basic knowledge or experience. This is a professional matter, in which responsibility lies with the individuals themselves as well as with their employers. Mortality is at an all-time low this year, but there is avoidable major morbidity. There were 12 cases of ABO-incompatible red cell transfusion this year, 9 arising from clinical error and 3 from laboratory error. The training and competency assessment required by the NPSA SPN 14 aims to reduce errors in phlebotomy, blood component collection and administration.
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