Serious Hazards of Transfusion (SHOT) Annual Report 2009
| dc.contributor.author | Serious Hazards of Transfusion (SHOT) | |
| dc.date.accessioned | 2023-03-04T13:58:05Z | |
| dc.date.available | 2023-03-04T13:58:05Z | |
| dc.identifier.citation | Serious Hazards of Transfusion (SHOT) Writing Group. (2010). Serious Hazards of Transfusion (SHOT) Annual Report 2009. Pgs 1-157. | en_US |
| dc.identifier.issn | 9780955864827 | |
| dc.identifier.uri | http://hdl.handle.net/20.500.12417/1362 | |
| dc.description | SHOT is affiliated to the Royal College of Pathologists | en_US |
| dc.description.abstract | This 2009 report is the 13th annual report of data and evidence-based recommendations produced by SHOT. In the first year of SHOT reporting, 1996/97, there were 36 cases in which patients suffered major morbidity from transfusion (excluding 3 cases of potential D sensitisation in young women/girls), plus 12 deaths, resulting in a serious outcome for 48/141 or 34%, of cases reported. For this 2009 report 1279 cases were analysed: there are 73 cases of major morbidity (excluding anti-D related potential for major morbidity), plus one death definitely related to transfusion and 12 deaths in which the transfusion reaction may have contributed. The total number of patients with serious outcomes is 86/1279, i.e. a fall to 6.7%. | |
| dc.language.iso | en | en_US |
| dc.subject | Serious Hazards of Transfusion | en_US |
| dc.subject | Blood Transfusion | en_US |
| dc.subject | Transfusion Reaction | en_US |
| dc.title | Serious Hazards of Transfusion (SHOT) Annual Report 2009 | en_US |
| dcterms.dateAccepted | 2022-11-14 | |
| rioxxterms.version | NA | en_US |
| rioxxterms.licenseref.uri | http://www.rioxx.net/licenses/all-rights-reserved | en_US |
| rioxxterms.type | Technical Report | en_US |
| refterms.dateFOA | 2023-03-04T13:58:05Z | |
| refterms.panel | Unspecified | en_US |
| html.description.abstract | This 2009 report is the 13th annual report of data and evidence-based recommendations produced by SHOT. In the first year of SHOT reporting, 1996/97, there were 36 cases in which patients suffered major morbidity from transfusion (excluding 3 cases of potential D sensitisation in young women/girls), plus 12 deaths, resulting in a serious outcome for 48/141 or 34%, of cases reported. For this 2009 report 1279 cases were analysed: there are 73 cases of major morbidity (excluding anti-D related potential for major morbidity), plus one death definitely related to transfusion and 12 deaths in which the transfusion reaction may have contributed. The total number of patients with serious outcomes is 86/1279, i.e. a fall to 6.7%. | en_US |
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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.
