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AbstractThis report has several changes from the 2009 report in that it includes a summary of mortality and morbidity, an analysis of near miss incidents, and a chapter related to the definitions of donor adverse events (see Chapters 5, 21 and 22, respectively). With respect to participation, only the overall participation rate and national figures are provided in the report, since each hospital or Trust will be benchmarked this year according to their issues of components. Recommendations from previous years and an update on their progress have now been posted on the website (www.shotuk.org).
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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.
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.
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.