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Annual SHOT Report 2020
Serious Hazards of Transfusion (SHOT) Medicines and Healthcare products Regulatory Agency (MHRA)
Serious Hazards of Transfusion (SHOT)
Medicines and Healthcare products Regulatory Agency (MHRA)
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Abstract
Key SHOT messages
• Ensuring transfusion teams are well resourced: Clinical and laboratory teams can function
optimally only if adequately staffed and well resourced. Healthcare leaders and management must
ensure that staff have access to the correct information technology (IT) equipment and financial
resources for safe and effective functioning
• Addressing knowledge gaps, cognitive biases, and holistic training: Transfusion training
with a thorough and relevant knowledge base in transfusion to all clinical and laboratory staff along
with training in patient safety principles, understanding human factors and quality improvement
approaches are essential. It is important that staff understand how cognitive biases contribute to
poor decision making so that they can be mitigated appropriately
• Patient safety culture: Fostering a strong and effective safety culture that is ‘just and learning’ is
vital to ensure reduction in transfusion incidents and errors, thus directly improving patient safety
• Standard operating procedures (SOP): SOP need to be simple, clear, easy to follow and
explain the rationale for each step. This will then ensure staff are engaged and more likely to be
compliant and follow the SOP
• Learning from near misses: Reporting and investigating near misses helps identify and control
risks before actual harm results, thus providing valuable opportunities to improve transfusion
safety
• Learning from the pandemic: The learning from the pandemic experiences should be captured
in every organisation, by everyone in healthcare and used to improve patient safety