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Annual SHOT Report 2013
Serious Hazards of Transfusion (SHOT)
Serious Hazards of Transfusion (SHOT)
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Abstract
The current risks from blood and blood component transfusion in the UK remains small with a risk of death at 8.0 and
risk of major morbidity 51.8 per 1,000,000 components issued. New strategies are required to reduce the level of error
in the transfusion process. Checklists are very useful to ensure all the steps of a process have been completed and
should be introduced for transfusion as recommended in 2011 (http://www.shotuk.org/resources/current-resources/ ). Any
unexpected transfusion reactions must be promptly recognised and treated and continue to be reported. Appropriate
local review of incidents including root cause analysis where indicated will help to identify systems problems which
can be remedied.
All staff involved in transfusion are reminded that they have a duty of care to report adverse events which potentially
or actually affect patient safety.