Serious Hazards of Transfusion scheme: a review of 2016 data

The Serious Hazards of Transfusion (SHOT) scheme collects and analyses anonymised information reported in the UK about serious adverse reactions and other serious adverse events (SAE) related to blood transfusion, then makes recommendations to improve patient and transfusion safety. From 2015, SHOT reports have included data for donor vigilance provided by the four UK Blood Services demonstrating the full range of haemovigilance from donor to recipient. This year, SHOT celebrated its 20th anniversary with the release of its 2016 Annual Report (assessing a total of 3091 case reports). 

Key recommendations

• A bedside checklist must be used at the patient’s side as a final administration check prior to transfusion as standard of care. The checklist must include positive patient identification (forename, surname, date of birth, and hospital number or other unique identifier). It should also confirm that the component is correct and has any specific requirements for that patient and that it has been prescribed for transfusion to this patient at this time. Errors are made with both one-person and two-person checks. Use of a verification process (two people working together, with challenge and response) may be more effective. Whatever bedside system is in place (including electronic systems), it should be assessed and include a validation step where someone has to sign to say that all steps have been followed and completed correctly.