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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.Collections
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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.