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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.Collections
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Annual SHOT Report 2021Serious 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.
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Annual SHOT Report 2018Serious 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.
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Annual SHOT Report 2013Serious 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.