Recent Submissions

  • Annual SHOT Report 2022

    Serious Hazards of Transfusion (SHOT); Medicines and Healthcare products Regulatory Agency (MHRA) (2022)
    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.
  • Annual SHOT Report 2020

    Serious Hazards of Transfusion (SHOT); Medicines and Healthcare products Regulatory Agency (MHRA) (2021)
    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
  • Serious Hazards of Transfusion (SHOT) Annual Report 2010

    Serious Hazards of Transfusion (SHOT) (2011)
    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).
  • Annual 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.
  • Annual SHOT Report 2019

    Serious Hazards of Transfusion (SHOT); Medicines and Healthcare products Regulatory Agency (MHRA)
    Accurate patient identification is fundamental to patient safety. Organisations must review all patient identification errors and address the causes of patient misidentification with use of electronic systems, and empowerment of patients and staff. Clinical and laboratory staff should be trained in fundamentals of transfusion, human factors, cognitive biases, investigating incidents and patient safety principles. All healthcare organisations should incorporate the principles of both Safety-I and Safety-II approaches to improve patient care and safety. Healthcare leaders should proactively seek signals for improvement from unsafe, suboptimal as well as excellent care. Healthcare management must recognise that safety and outcomes are multifaceted, a linear view of safety does not fully acknowledge the interdependencies of resources including their leadership, adequate staffing and knowledge. Healthcare leaders should ensure these are all in place to improve patient safety.
  • Annual SHOT Report 2018

    Serious Hazards of Transfusion (SHOT); Medicines and Healthcare products Regulatory Agency (MHRA)
    All NHS organisations must move away from a blame culture towards a just and learning culture. All clinical and laboratory staff should be encouraged to become familiar with human factors and ergonomics concepts. All transfusion decisions must be made after carefully assessing the risks and benefits of transfusion therapy. Collaboration and co-ordination among staff is vital.
  • Annual SHOT Report 2017

    Serious Hazards of Transfusion (SHOT); Medicines and Healthcare products Regulatory Agency (MHRA)
    Training in ABO and D blood group principles is essential for all laboratory nd clinical staff with any responsibility for the transfusion process. This should form part of the competency assessments. All available information technology (IT) systems to support transfusion practice should be considered and these systems implemented to their full functionality. Electronic blood management systems should be considered in all clinical settings where transfusion takes place. This is no longer an innovative approach to safe transfusion practice, it is the standard that all should aim for. A formal pre-transfusion risk assessment for transfusion-associated circulatory overload (TACO) should be undertaken whenever possible, as TACO is the most commonly reported cause of transfusionrelated mortality and major morbidity (repeat from last year)
  • Annual SHOT Report 2016

    Serious Hazards of Transfusion (SHOT); Medicines and Healthcare products Regulatory Agency (MHRA)
    ABO-incompatible transfusions are the tip of the iceberg; they most commonly result from failure to identify the patient at the time of blood sampling (wrong blood in tube) or administration to the wrong patient. Pulmonary complications, particularly transfusion-associated circulatory overload (TACO), cause the most deaths and major morbidity. Delayed transfusions are an important cause of death, 25/115 (21.7%) 2010 to 2016. Many errors in transfusion, some with serious clinical consequences, relate to poor communication between teams, shifts and interfaces. The infrastructure needs improvement to facilitate exchange of results within and between hospitals. IT errors contributed to 1 in 5 SAE reported. IT is not infallible, it makes transfusion practice safer by helping to control and support the task, but does not replace knowledge about the task.
  • Annual SHOT Report 2015

    Serious Hazards of Transfusion (SHOT); Medicines and Healthcare products Regulatory Agency (MHRA)
    Be WARM: Work Accurately and Reduce Mistakes 1. Use a TACO checklist 2. Use a bedside checklist TACO Checklist Red Cell Transfusion for Non-Bleeding Patients. Human factors in hospital practice. Be safe! Use the bedside checklist. • Review the need for transfusion (do the benefits outweigh the risks)? • Can the transfusion be safely deferred until the issue can be investigated, treated or resolved? • Consider body weight dosing for red cells (especially if low body weight) • Transfuse one unit (red cells) and review symptoms of anaemia • Measure the fluid balance • Consider giving a prophylactic diuretic • Monitor the vital signs closely, including oxygen saturation
  • Annual SHOT Report 2014

    Serious Hazards of Transfusion (SHOT); Medicines and Healthcare products Regulatory Agency (MHRA)
    Blood and blood component transfusion in the UK is very safe with a small number of adverse incidents in relation to the number of components issued and transfused. In 2014 (January to December) the total number of reports made to SHOT was 3668 and 3017 were analysed for this Annual Report (others were incomplete or withdrawn). The total number of reports made to the Medicines and Healthcare products Regulatory Agency (MHRA) was 1110 of which 764 were serious adverse events (errors in 97.8%) and 346 were serious adverse reactions. The proportion of SHOT reports where errors were the underlying cause was similar to 2013, 77.8% (2346 reports). Acute transfusion reactions (allergic/febrile) were the most common pathological reactions. The cumulative data (18 years) can be viewed on the website www.shotuk.org.
  • Annual SHOT Report 2013

    Serious Hazards of Transfusion (SHOT)
    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.
  • Annual SHOT Report 2012

    Serious Hazards of Transfusion (SHOT)
    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
  • Annual SHOT Report 2011

    Serious Hazards of Transfusion (SHOT)
    Transfusion of blood components in the UK remains remarkably safe, with the risk of death 0.0027 and risk of major morbidity 0.0396 per 1000 components issued respectively. However, the level of error in the transfusion process is a cause for concern, indicating the need for continued education, which should underpin competency assessment, and vigilance. Checklists are very useful to ensure all the steps of a process have been completed. Any unexpected transfusion reactions must be promptly recognised and treated and continue to be reported to ensure patient safety, particularly with the advent of new products and changing policies in relation to CMV screening. All staff involved in transfusion should remain aware that they have a duty of care to report adverse events which potentially or actually affect patient safety.
  • Serious Hazards of Transfusion (SHOT) Annual Report 2009

    Serious Hazards of Transfusion (SHOT)
    This 2009 report is the 13th annual report of data and evidence-based recommendations produced by SHOT. In the first year of SHOT reporting, 1996/97, there were 36 cases in which patients suffered major morbidity from transfusion (excluding 3 cases of potential D sensitisation in young women/girls), plus 12 deaths, resulting in a serious outcome for 48/141 or 34%, of cases reported. For this 2009 report 1279 cases were analysed: there are 73 cases of major morbidity (excluding anti-D related potential for major morbidity), plus one death definitely related to transfusion and 12 deaths in which the transfusion reaction may have contributed. The total number of patients with serious outcomes is 86/1279, i.e. a fall to 6.7%.
  • Serious Hazards of Transfusion (SHOT) Annual Report 2008

    Serious Hazards of Transfusion (SHOT)
    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
  • Serious Hazards of Transfusion (SHOT) Annual Report 2007

    Serious Hazards of Transfusion (SHOT)
    The issues surrounding education and training raised in the 2006 report are emphasised by the findings for 2007. There remains evidence that junior doctors are making critical decisions without adequate basic knowledge or experience. This is a professional matter, in which responsibility lies with the individuals themselves as well as with their employers. Mortality is at an all-time low this year, but there is avoidable major morbidity. There were 12 cases of ABO-incompatible red cell transfusion this year, 9 arising from clinical error and 3 from laboratory error. The training and competency assessment required by the NPSA SPN 14 aims to reduce errors in phlebotomy, blood component collection and administration.
  • Serious Hazards of Transfusion (SHOT) Annual Report 2006

    Serious Hazards of Transfusion (SHOT)
    The year’s key recommendations focus on the need for integration of transfusion medicine into the teaching and training curricula for junior hospital doctors, and nursing and scientific staff involved in transfusion. This goes beyond assessment of basic competencies and is recognising the need for solid knowledge and understanding of transfusion therapies so that sound decisions can be made in clinical practice. As previously, these recommendations have been made after consultation with stakeholders to ensure support for their implementation. The final responsibility for ensuring action in relation to hospital-based recommendations lies with Trust Chief Executive Officers (CEOs), though the day-to-day responsibility may be delegated to members of the Hospital Transfusion Team (HTT). The recommendations this year appear in three sections of the full SHOT report: SHOT Recommendations of the Year, Active recommendations from previous years: update, Specific recommendations relevant to each reporting category.
  • Serious Hazards of Transfusion (SHOT) Annual Report 2005

    Serious Hazards of Transfusion (SHOT)
    Recommendations for future developments 1 Blood transfusion outside the hospital setting: Against the background of a trend towards provision of care closer to the patient, there is a need for a standard of practice to be developed for transfusion in the community setting, including provision for appropriate management and reporting of adverse events 2 Need for clinical studies: There is a paucity of good quality randomised studies from which to develop evidence-based transfusion practice. Well designed clinical studies should be undertaken to answer some of the questions that arise in clinical practice, including the optimal methods of patient identification, systems organisation and appropriate blood product support in different clinical settings. This will require action from clinical researchers, statistical & analytical support and assistance from funding bodies. 3 Future development of haemovigilance: The implementation of the Blood Safety and Quality Regulations provides a unique opportunity to develop and re-enforce haemovigilance in the UK. It is essential that a structure is established that enables UK haemovigilance to flourish and to maintain its international recognition.
  • Serious Hazards of Transfusion (SHOT) Annual Report 2004

    Serious Hazards of Transfusion (SHOT)
    2004 was a momentous one for all involved in the provision of blood transfusion, with the implementation of the European Union (EU) Directive on Blood Safety and Quality. The Directive was incorporated into UK legislation on 8th February 2005 as the Blood Safety and Quality Regulations, and will be implemented on 8th November. It requires that Blood Establishments and Hospital Blood Banks report to the Secretary of State for Health, 'all serious adverse reactions attributable to the safety or quality of blood', and 'all serious adverse events related to the collection, testing, processing, storage and distribution of blood and blood components that may have an influence on their quality and safety'. The EU Directive does not encompass no harm errors in clinical areas, which account for 70% of Incorrect Blood Components Transfused (IBCT) events. It is therefore vital that hospitals continue to report these events to SHOT in order to preserve the safety culture that we have established in the UK and to provide continuity of data for monitoring of the NPSA/NBTC/SHOT initiative outlined below, and other blood safety initiatives.
  • Serious Hazards of Transfusion (SHOT) Annual Report 2003

    Serious Hazards of Transfusion (SHOT)
    With this 7th annual report, SHOT provides an increasingly authoritative analysis of serious transfusion hazards in the UK and an evidence base for blood safety initiatives, policies and guidelines. This report is condensed to make it more user-friendly with detailed data available on the SHOT website www.shot-uk.org. Recommendations are targeted at specific groups or bodies to maximise their effectiveness.

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