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Annual SHOT Report 2012
Serious Hazards of Transfusion (SHOT)
Serious Hazards of Transfusion (SHOT)
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Abstract
The investigation report produced some key findings:
– Only one unit of blood should be removed from storage at any time – the nurse collecting took three units for three separate patients at the same time
– The final administration check should always be conducted next to the patient by two registered nurses, and once all checks have been completed, the transfusion should be started immediately – the staff did not commence transfusion immediately after an initial check of the units, but placed the units on a table before picking them up again, so the final bedside check was not performed properly
– Transfusion must only take place where there are enough staff available to monitor the patient and when the patient can readily be observed – a second nurse who had assisted in the checking procedures had returned to her ward, leaving one nurse in the day unit to administer and monitor three transfusions, including leaving the ward unsupervised while she went to collect further units