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
Bellamy, Mark
Narayan, Shruthi
Spinks, Courtney
Davies, Jennifer
Poles, Debbi
Milser, Emma
Carter-Graham, Simon
Tuckley, Victoria
Flannagan, Joe
Yawitch, Tali
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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