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  • Annual SHOT Report 2020

    Bellamy, Mark; Narayan, Shruthi; Spinks, Courtney; Davies, Jennifer; Poles, Debbi; Milser, Emma; Carter-Graham, Simon; Tuckley, Victoria; Flannagan, Joe; Yawitch, Tali
    Transfusion delays, particularly in major haemorrhage and major trauma situations, must be prevented. Delays in provision and administration of blood components including delays in anticoagulant reversal, particularly in patients with intracranial haemorrhage, can result in death, or serious sequelae. Every minute counts in these situations. Effective and reliable transfusion information technology systems should be implemented to reduce the risk of errors at all steps in the transfusion pathway, provided they are configured and used correctly. Effective investigation of all incidents and near miss events, application of effective corrective and preventive actions, and closing the loop by measuring the effectiveness of interventions should be carried out to optimise learning from incidents Taken from Key recommendations from summary: Full text available at: