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Serious Hazards of Transfusion (SHOT) Annual Report 2008
Serious Hazards of Transfusion (SHOT)
Serious Hazards of Transfusion (SHOT)
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Abstract
The 12th SHOT Annual Report was published at the end of June 2009 to coincide with the submission of haemovigilance data
to the EU Commission by the competent authority, the Medicines and Healthcare products Regulatory Agency (MHRA).
Over 12 years of reporting, the trends observed by SHOT have borne the hallmarks of an effective vigilance system. The
number of events reported has risen, while the frequency of the most serious events, and the mortality directly related
to transfusion, has fallen. As the culture of reporting has developed, there has been an increased understanding of how
an adverse event system exerts its influence, i.e. by the observation and reporting of trends and patterns, followed by
changes of practice to reduce the risks of recurrence, rather than by the creation of a ‘blame culture’.
SHOT demonstrates the utility of an effective haemovigilance system in increasing patient safety through the promotion
of a culture of learning and improvement, with an emphasis on safety and quality