NHS Blood and Transplanthttp://hdl.handle.net/20.500.12417/13032024-03-23T08:05:57Z2024-03-23T08:05:57ZAnnual SHOT Report 2022Serious Hazards of Transfusion (SHOT)Medicines and Healthcare products Regulatory Agency (MHRA)http://hdl.handle.net/20.500.12417/15252024-03-01T10:26:15Z2022-01-01T00:00:00ZAnnual SHOT Report 2022
Serious Hazards of Transfusion (SHOT); Medicines and Healthcare products Regulatory Agency (MHRA)
Key SHOT messages • Reporting levels have increased again after the slight reduction during the COVID-19 pandemic • Analysis shows potential under-reporting from some NHS organisations. It is important that healthcare organisations submit reports across all types of reporting categories i.e., errors, reactions and near misses • Reports where the error occurred in the ED have almost doubled since 2020 Abstract published with permission.
2022-01-01T00:00:00ZAnnual SHOT Report 2020Serious Hazards of Transfusion (SHOT)Medicines and Healthcare products Regulatory Agency (MHRA)http://hdl.handle.net/20.500.12417/13742023-03-05T01:05:16Z2021-01-01T00:00:00ZAnnual SHOT Report 2020
Serious Hazards of Transfusion (SHOT); Medicines and Healthcare products Regulatory Agency (MHRA)
Key SHOT messages • Ensuring transfusion teams are well resourced: Clinical and laboratory teams can function optimally only if adequately staffed and well resourced. Healthcare leaders and management must ensure that staff have access to the correct information technology (IT) equipment and financial resources for safe and effective functioning • Addressing knowledge gaps, cognitive biases, and holistic training: Transfusion training with a thorough and relevant knowledge base in transfusion to all clinical and laboratory staff along with training in patient safety principles, understanding human factors and quality improvement approaches are essential. It is important that staff understand how cognitive biases contribute to poor decision making so that they can be mitigated appropriately • Patient safety culture: Fostering a strong and effective safety culture that is ‘just and learning’ is vital to ensure reduction in transfusion incidents and errors, thus directly improving patient safety • Standard operating procedures (SOP): SOP need to be simple, clear, easy to follow and explain the rationale for each step. This will then ensure staff are engaged and more likely to be compliant and follow the SOP • Learning from near misses: Reporting and investigating near misses helps identify and control risks before actual harm results, thus providing valuable opportunities to improve transfusion safety • Learning from the pandemic: The learning from the pandemic experiences should be captured in every organisation, by everyone in healthcare and used to improve patient safety
SHOT is affiliated to the Royal College of Pathologists. This report is produced by SHOT working with MHRA
2021-01-01T00:00:00ZSerious Hazards of Transfusion (SHOT) Annual Report 2010Serious Hazards of Transfusion (SHOT)http://hdl.handle.net/20.500.12417/13732023-03-05T01:07:31Z2011-01-01T00:00:00ZSerious Hazards of Transfusion (SHOT) Annual Report 2010
Serious Hazards of Transfusion (SHOT)
This report has several changes from the 2009 report in that it includes a summary of mortality and morbidity, an analysis of near miss incidents, and a chapter related to the definitions of donor adverse events (see Chapters 5, 21 and 22, respectively). With respect to participation, only the overall participation rate and national figures are provided in the report, since each hospital or Trust will be benchmarked this year according to their issues of components. Recommendations from previous years and an update on their progress have now been posted on the website (www.shotuk.org).
SHOT is affiliated to the Royal College of Pathologists
2011-01-01T00:00:00ZAnnual SHOT Report 2021Serious Hazards of Transfusion (SHOT)Medicines and Healthcare products Regulatory Agency (MHRA)http://hdl.handle.net/20.500.12417/13722023-03-05T01:06:41ZAnnual SHOT Report 2021
Serious Hazards of Transfusion (SHOT); Medicines and Healthcare products Regulatory Agency (MHRA)
Partnering with patients to enhance safety: Staff must ensure that they involve, engage and listen to patients as ‘partners’ in their own care, including transfusion support. Engaging patients, their families, and carers as ‘safety partners’ helps co-create safer systems, identify, and rectify preventable adverse events. Investing in safety - well-resourced systems with safe staffing levels: Healthcare leaders must ensure that systems are designed to support safe transfusion practice and allocate adequate resources in clinical and laboratory areas to ensure safe staffing levels, staff training in technical and non-technical skills and appropriate equipment, including IT systems. Just and learning safety culture: All healthcare leaders must promote a just, learning safety culture with a collective, inclusive, and compassionate leadership. Effective leaders must ensure staff have: access to adequate training, mentorship, and support. All staff in clinical and laboratory areas have a responsibility to speak up in case of any concerns and help embed the safety culture in teams.
SHOT is affiliated to the Royal College of Pathologists. This report is produced by SHOT working with MHRA