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    Annual SHOT Report 2020

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    Author
    Bellamy, Mark
    Narayan, Shruthi
    Spinks, Courtney
    Davies, Jennifer
    Poles, Debbi
    Milser, Emma
    Carter-Graham, Simon
    Tuckley, Victoria
    Flannagan, Joe
    Yawitch, Tali
    Keyword
    Error Reports
    Error Reports With No Harm
    Reactions in Patients
    Special Clinical Groups
    Blood Transfusion
    Serious Hazards of Transfusion
    
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    URI
    http://hdl.handle.net/20.500.12417/1318
    Abstract
    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: https://www.shotuk.org/wp-content/uploads/myimages/SHOT-Summary-ZCard-2020-v2.2.pdf Full text available at: https://www.shotuk.org/wp-content/uploads/myimages/SHOT-REPORT-2020.pdf
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    NHS Blood and Transplant

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