Serious Hazards of Transfusion (SHOT) Annual Report 2006
Abstract
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.Collections
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Annual SHOT Report 2021Partnering 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 2018All 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 2013The 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.
